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Hiatus Hernia

By Kristle Lee Lynch, MD, Assistant Professor of Medicine, Perelman School of Medicine at The University of Pennsylvania

Hiatus hernia is an abnormal bulging of a portion of the stomach through the diaphragm.

  • 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 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) or from an injury.

Types of hiatus hernia

There are two main types of hiatus hernia.

  • Sliding hiatus hernia (most common)

  • Paraesophageal 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. The frequency increases with age, 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.

Understanding Hiatus Hernia

A hiatus hernia is an abnormal bulging of a portion of the stomach through the diaphragm.

Symptoms

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 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.

Rarely, microscopic or massive bleeding from the lining of the hernia occurs with either type of hiatus hernia.

Diagnosis

  • Chest x-ray

  • Barium swallow x-rays

  • Sometimes upper endoscopy

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). The barium outlines the esophagus, making abnormalities easier to see.

Hernias can also be seen during an upper endoscopy. During upper endoscopy, doctors examine the esophagus by using a flexible tube called an endoscope.

Treatment

  • Measures to prevent or treat acid reflux

  • Sometimes a proton pump inhibitor

  • Sometimes surgery

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 Peptic Ulcer Disease). 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.

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