The cause of this disorder usually is not known, but age, obesity, and smoking are common factors.
Some people have no symptoms or minor ones such as reflux and indigestion, whereas others have more serious symptoms such as chest pain, bloating, belching, and difficulty swallowing.
The diagnosis is based on results of barium swallow x-rays or sometimes upper endoscopy.
Treatment is aimed at relieving symptoms, sometimes by using drugs and rarely by doing surgery.
The esophagus Throat and Esophagus The throat (pharynx—see also Throat) lies behind and below the mouth. When food and fluids leave the mouth, they pass through the throat. Swallowing of food and fluids begins voluntarily and... read more is the hollow tube that leads from the throat (pharynx) to the stomach.
Bulging (herniating) 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 called the hiatus. A diaphragmatic hernia that occurs through this opening is called a hiatus hernia.
The cause of hiatus hernia is usually unknown, but it may be caused by stretching of the bands of tissue that are attached between the esophagus and diaphragm at the hiatus. 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 Diaphragmatic Hernia Diaphragmatic Hernia A diaphragmatic hernia is a birth defect in which a hole or weakening in the diaphragm allows some of the abdominal organs to protrude into the chest. This defect causes severe difficulty breathing... read more ) 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, bulge above it. More than 40% of people in the United States have a sliding hiatus hernia and the frequency increases in 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 Gastroesophageal Reflux Disease (GERD) In gastroesophageal reflux disease, stomach contents, including acid and bile, flow backward from the stomach into the esophagus, causing inflammation in the esophagus and pain in the bottom... read more and include indigestion, typically when a person lies down after eating. However, less than 50% of people with hiatus hernia have gastroesophageal reflux disease. Leaning forward, straining, and lifting heavy objects make symptoms worse, as does pregnancy.
A paraesophageal hiatus hernia typically causes no symptoms but 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 Difficulty Swallowing Some people have difficulty swallowing (dysphagia). In dysphagia, foods and/or liquids do not move normally from the throat (pharynx) to the stomach. People feel as though food or liquids become... read more .
Rarely, microscopic or massive bleeding from the lining of the hernia occurs with either type of hiatus hernia.
Doctors can often see a large hiatus hernia on a chest x-ray. Otherwise, people are given barium in a liquid before x-rays are taken (barium swallow X-Ray Studies of the Digestive Tract X-rays often are used to evaluate digestive problems. Standard x-rays (plain x-rays) do not require any special preparation (see Plain X-Rays). These x-rays usually can show a blockage or paralysis... read more ). The barium outlines the esophagus, making abnormalities easier to see.
Hernias can also be seen during an upper endoscopy Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). Endoscopy can also be used to treat many disorders because doctors are able to pass instruments... read more . During upper endoscopy, doctors examine the esophagus by using a flexible tube called an endoscope Endoscopy Endoscopy is an examination of internal structures using a flexible viewing tube (endoscope). Endoscopy can also be used to treat many disorders because doctors are able to pass instruments... read more .
Sliding hiatus hernias that do not cause symptoms do not require treatment. If symptoms of reflux occur, doctors give a proton pump inhibitor, which reduces acid production (see Table: Drugs Used to Treat Stomach Acid Drugs Used to Treat Stomach Acid Stomach acid plays a role in a number of disorders of the stomach, including peptic ulcer, gastritis, and gastroesophageal reflux disease (GERD). Although the amount of acid present in the stomach... read more ).
Other helpful measures for treating reflux include elevating the head of the bed while sleeping, 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, and spicy, acidic, and fatty foods) is recommended.
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 through which thin instruments and a small video camera are inserted (thoracoscopic or laparoscopic surgery) or may require a full open operation.