Hiatus hernia is a protrusion of a portion of the stomach across the opening in the diaphragm that the esophagus normally passes through.
Protrusion of any structure in the abdomen through the diaphragm (the sheet of muscle that separates the chest cavity from the abdomen) is called a diaphragmatic hernia. The diaphragm has an opening that the esophagus normally passes through (the hiatus). A diaphragmatic hernia that occurs through this opening is called a hiatus hernia. The cause of hiatus hernia is usually unknown, but the condition is more common among people who are older than 50, who are overweight (particularly women), or who smoke. Other types of diaphragmatic hernia may result from a birth defect (see Birth Defects: Diaphragmatic Hernia) or from an injury.
There are two main types of hiatus hernia. In a sliding hiatus hernia, the junction between the esophagus and the stomach as well as a portion of the stomach itself, all of which are normally below the diaphragm, protrude above it. More than 40% of people in the United States have a sliding hiatus hernia. The frequency increases with aging, so that the rate climbs to 60% of people older than 60.
In a paraesophageal hiatus hernia, the junction between the esophagus and stomach is in its normal place below the diaphragm, but a portion of the stomach is pushed above the diaphragm and lies beside the esophagus.
Most sliding hiatus hernias are very small, and most people with a sliding hiatus hernia have no symptoms. Symptoms that do occur are usually minor. They are usually related to gastroesophageal reflux (see Peptic Disorders: Gastroesophageal Reflux (GERD)) and include indigestion, typically when a person lies down after eating. Leaning forward, straining, and lifting heavy objects make symptoms worse, as does pregnancy.
A paraesophageal hiatus hernia may get trapped or pinched by the diaphragm and lose its blood supply. This serious and painful condition, called strangulation, requires immediate surgery. Symptoms may include chest pain, bloating, belching, and difficulty swallowing
Rarely, microscopic or massive bleeding from the lining of the hernia occurs with either type of hiatus hernia.
Diagnosis and Treatment
Usually, x-rays clearly reveal a hiatus hernia, although a doctor may have to press on the abdomen during the procedure to make the hernia visible. Often, people are given barium in a liquid before the x-ray. Barium outlines the digestive tract, making abnormalities easier to see.
Most sliding hiatus hernias do not require treatment, but if symptoms of reflux occur, elevating the head of the bed while sleeping often helps. Other helpful measures for reflux include eating small meals, losing excess weight, stopping smoking, not lying down or exercising after meals, and not wearing tight-fitting clothes. Eliminating or limiting intake of beverages that contain acid (such as orange juice and colas), alcohol, coffee, and certain foods (such as onions, chocolate, and spicy, acidic, and fatty foods) is recommended. Antacids and drugs that prevent acid production also relieve symptoms (see Peptic Disorders: Peptic Ulcer).
A paraesophageal hiatus hernia that causes symptoms should be corrected surgically to prevent strangulation. Surgery may be done through a tiny incision in the chest or abdomen and using a small viewing tube (laparoscopic surgery) or may require a full open operation.
Last full review/revision June 2006 by Sidney Cohen, MD