A hiatus hernia, also known as a hiatal hernia, occurs when part of the stomach pushes up through the diaphragm into the chest cavity. The diaphragm is the muscle that separates the chest cavity from the abdominal cavity. Normally, the stomach is located below the diaphragm, but in the case of a hiatus hernia, the upper part of the stomach protrudes through the hiatus, an opening in the diaphragm through which the esophagus passes.
Types of Hiatus Hernia:
- Sliding Hiatus Hernia: This is the most common type, where the gastroesophageal junction (where the stomach and esophagus meet) and a portion of the stomach slide up into the chest. This type can move back and forth and is often associated with gastroesophageal reflux disease (GERD).
- Paraesophageal Hiatus Hernia: Less common but potentially more serious, in this type, part of the stomach pushes through the hiatus alongside the esophagus, while the gastroesophageal junction remains in its normal position. This can cause the stomach to become “strangled,” leading to a risk of reduced blood supply.
Symptoms: Many people with a hiatus hernia have no symptoms. However, when symptoms do occur, they can include:
- Heartburn
- Regurgitation of food or liquids
- Difficulty swallowing
- Chest or abdominal pain
- Feeling full quickly after eating
- Shortness of breath, especially if a large portion of the stomach is involved
Diagnosis: Hiatus hernias are often diagnosed during tests for other conditions, particularly if GERD is suspected. Diagnostic tests include:
- Upper GI Series (Barium Swallow): This X-ray examination involves swallowing a barium solution to highlight the esophagus and stomach on X-rays.
- Endoscopy: A flexible tube with a light and camera (endoscope) is passed down the throat to examine the esophagus and stomach.
- Esophageal Manometry: Measures the rhythmic muscle contractions in your esophagus when you swallow, the coordination and force exerted by the esophageal muscles, and the function of the lower esophageal sphincter.
Treatment: Treatment depends on the severity of the hernia and the symptoms:
- Lifestyle and Dietary Changes: These include eating smaller, more frequent meals, avoiding foods and drinks that trigger reflux, not lying down after eating, and losing weight if necessary.
- Medications: To reduce stomach acid and manage symptoms, such as antacids, H-2-receptor blockers, and proton pump inhibitors (PPIs).
- Surgery: Indicated if the hernia is large, symptomatic, or causing complications. Surgical options include:
- Nissen Fundoplication: The top part of the stomach is wrapped around the lower esophagus to strengthen the esophageal sphincter, prevent acid reflux, and repair the hernia.
- Paraesophageal Hernia Repair: Involves pulling the stomach down into the abdomen, reducing the hernia, repairing the diaphragm, and sometimes gastropexy (attaching the stomach to the abdominal wall).
Case Example: A 55-year-old woman presents with a history of persistent heartburn, regurgitation, and chest discomfort. She reports that symptoms worsen after meals and when lying down. She has been using over-the-counter antacids with minimal relief.
Diagnostic Workup:
- Barium Swallow: Reveals a sliding hiatus hernia.
- Endoscopy: Shows evidence of esophagitis but no significant Barrett’s esophagus.
Management Plan:
- Lifestyle Modifications: Recommendations to elevate the head of her bed, avoid late meals, reduce fatty food intake, and maintain a healthy weight.
- Medications: Prescribed a proton pump inhibitor (omeprazole) to manage acid reflux.
- Follow-up: Scheduled to monitor symptoms and adjust treatment as needed.
If her symptoms persist or complications arise, surgical consultation for potential hiatal hernia repair may be considered.