What is a hiatus hernia?
A hiatus hernia is a common condition where a part of the stomach slides or protrudes from the abdomen into the chest. Most hiatus hernias don’t cause any problems, but some – especially large hiatus hernias – cause symptoms such as heartburn. There are treatments available, including self-help measures, medicines and surgery.
What are the symptoms of hiatus hernia?
Many people with small hiatus hernias have no symptoms at all and may never know they have the condition unless it is discovered by accident as part of an investigation for another problem. When symptoms do occur, the most common symptoms are those arising from gastro-oesophageal reflux, which can occur as a result of the hernia.
- Heartburn – a painful burning sensation felt in the lower front chest area behind the breastbone and upper abdomen, often after eating or when lying down.
- Regurgitation of sour or bitter-tasting acid fluid into the mouth, particularly at night, which occurs with more severe reflux.
These symptoms are often worse when you bend over, lie down or strain to lift heavy objects.
Depending on the type of hiatus hernia you have, other symptoms can include:
- belching or burping;
- difficulty in swallowing; and
- pain on swallowing (especially hot drinks).
What causes a hiatus hernia?
The chest and abdomen are normally separated by the diaphragm, a thin sheet of muscle that aids in breathing. The oesophagus (the tube that food passes down from the mouth to the stomach) goes down through the chest, passing through a small opening (called a hiatus) in the diaphragm and entering the abdominal cavity to join the stomach.
Hiatus hernias can occur when there is weakening of the muscle tissue around the gap where the oesophagus passes through the diaphragm or where this gap is otherwise stretched. This allows a portion of the stomach to slide upwards through the opening in the diaphragm, beside the oesophagus, into the chest.
A number of risk factors appear to contribute to hiatus hernias developing including:
- hereditary factors;
- sudden, hard physical exertion, such as lifting;
- a birth defect; and
- trauma or surgery to the abdominal area.
Types of hiatus hernia
There are 2 main types of hiatus hernia.
Sliding hiatus hernia is the most common type, accounting for about 90 per cent of cases. It occurs when the junction between the oesophagus and the upper part of the stomach protrude up through the oesophageal opening in the diaphragm into the chest cavity. The herniated portion of the stomach can slide back and forth, into and out of the chest.
Rolling hiatus hernia (sometimes called a para-oesophageal hiatus hernia) is the other type. In this case, the junction of the oesophagus and stomach stays down within the abdomen, and the top part of the stomach (the fundus) bulges up into the chest cavity. This type of hernia normally remains in one place, sitting next to the oesophagus, and does not move in or out when you swallow.
Who gets hiatus hernia?
Most hiatus hernias are seen in adults, and about 30 per cent of people over the age of 50 will have a hiatus hernia, although they may not know about it. Women are affected more often than men. Hiatus hernias are often seen in people who are overweight and in pregnant women.
Complications of hiatus hernia
Complications are usually due to severe, ongoing reflux or having a very large hiatus hernia.
In some people with hiatus hernia, the acidic stomach contents regurgitate (reflux) regularly into the oesophagus. In severe cases, ongoing reflux may cause damage to the oesophagus and even bleeding that may lead to anaemia in some cases. Ongoing reflux may cause injury to the oesophagus and a narrowing of the oesophagus (called a stricture) that can cause swallowing difficulties.
Long-term gastro-oesophageal reflux disease can also cause changes to the cells in the lining of the lower oesophagus — a condition known as Barrett’s oesophagus. Having Barrett’s oesophagus puts you at increased risk of oesophageal cancer.
A rare complication of rolling hiatus hernias is a condition known as strangulation. This is where the protruding part of the stomach becomes twisted or pinched by the diaphragm. This can cause bloating, blockage of the oesophagus or problems swallowing.
Very rarely, the blood supply to the stomach can become blocked, and this can cause severe chest pain and breathing difficulties. This is a medical emergency and surgical treatment is needed immediately.
Sometimes with large hiatus hernias, there is so much of the stomach protruding into the chest that it presses on your lungs and can make breathing more difficult. See your doctor if you are having difficulty breathing.
How is a hiatus hernia diagnosed?
The most common symptoms caused by hiatus hernia are usually those due to gastro-oesophageal reflux. For this reason, hiatus hernia is often hard to tell apart from reflux just based on symptoms.
It’s important to not assume that you have a hiatus hernia based on symptoms alone. Always see your doctor for a proper diagnosis.
Hiatus hernia is most commonly diagnosed when doctors do an endoscopy to investigate reflux, or when a barium X-ray has been performed. The hiatus hernia can show up as a bulge that is positioned between the oesophagus and your stomach. Large hiatus hernias can be observed on plain chest X-rays.
A barium swallow test or barium meal is a test in which you will be asked to drink a chalky liquid containing barium that helps your internal organs show up more clearly on X-ray pictures. The barium will outline your gullet, stomach and upper part of your small intestine. This test may help your doctor see whether you have a hiatus hernia.
Endoscopy or gastroscopy
Another way your doctor may check for a hiatus hernia is by referring you for a gastroscopy, which is an endoscopic examination. This is where you are given a light sedative and a doctor will insert a thin flexible lighted tube (an endoscope) down into your oesophagus (gullet).
The tube allows the doctor to ‘look’ at your oesophagus and check for abnormalities. This common procedure is usually painless and is generally performed in day surgery centres in public or private hospitals.
How is a hiatus hernia treated?
In most cases, symptoms from a hiatus hernia can be kept under control with medicines and lifestyle changes that treat gastro-oesophageal reflux — your doctor can help you with these.
Surgery is normally only required if your symptoms become worse and more constant. Rolling, or para-oesophageal, hernias are more likely to require surgery than sliding hiatus hernias.
If you have gastro-oesophageal reflux symptoms from a hiatus hernia, there are a number of things you can do to help.
Self-care measures to help ease heartburn include the following.
- Eat a number of smaller meals rather than 3 larger meals each day. This will help put less pressure on your stomach.
- Drink most fluids between meals (rather than at meal times). Try avoiding carbonated beverages.
- Try avoiding foods and beverages that can aggravate symptoms of reflux, such as citrus fruits, spicy foods, chocolate, tomato-based foods, alcohol, and caffeine-containing drinks such as tea, coffee and cola.
- Avoid fatty foods, as they relax the sphincter muscle in your lower oesophagus and slow down stomach emptying, which allows more time for acid to reflux into your oesophagus.
- Try to wait a couple of hours after eating before you do any exercise.
- Do not lie down after eating. Always wait at least 2 to 3 hours before lying down or going to bed. By then, most of your food will have passed into your small intestine and can’t flow back into your oesophagus.
- Raise the head of your bed by about 10-20 cm if you can. The effects of gravity will help stop stomach acid from moving into your oesophagus when you’re asleep. It’s best to raise the head of the bed by inserting something (such as a piece of wood or a brick) between the floor and the bed at the head end, rather than using pillows to do this, because pillows tend to increase pressure on your abdomen.
- Avoid bending over or stooping, especially after eating. Do not lift very heavy objects that cause you to strain. Anything that increases pressure in your abdomen can help push your hiatus hernia further through your diaphragm.
- Try not to wear tight clothing that restricts your chest and stomach.
- If you are taking non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief and are suffering from heartburn, you may need to change your medication. Certain medicines, including NSAIDs, can affect stomach acid secretion. Talk to your doctor if you are unsure.
- Give up smoking! Smoking increases stomach acid reflux.
- If you are overweight, losing weight is one of the most important things you can do to reduce the pressure on your stomach and reduce symptoms. Discuss with your doctor a safe weight loss plan that is suitable for you.
If these self-care measures are not controlling your symptoms, your doctor may recommend further treatments.
Medicines for gastro-oesophageal reflux symptoms
There are several prescription and over-the-counter medicines that can help ease the reflux symptoms associated with hiatus hernia.
Antacids are available from pharmacies and include:
- calcium carbonate (e.g. Andrews TUMS Antacid);
- aluminium hydroxide (e.g. Alu-Tab); and
- mixtures containing several preparations (e.g. Gaviscon, Mylanta).
Antacids ease pain by working against the excess acid in your oesophagus to neutralise it. They won’t stop the acid from being produced, so be aware that if you stop taking them, it’s very likely your symptoms will return.
Side effects of antacids can include diarrhoea and constipation.
Histamine blocker medications
Histamine blockers, known as H2-blockers or H2-receptor antagonists, reduce the amount of acid your stomach secretes. They include:
- cimetidine (brand name Tagamet, Magicul);
- famotidine (Pepzan);
- nizatidine (Tazac, Tacidine); and
- ranitidine (Zantac, Rani 2, Ranoxyl).
Possible side effects of H2-receptor antagonists include diarrhoea, tiredness and headaches.
Small packs of ranitidine (Zantac Relief, Ranoxyl Heartburn Relief) are available from the pharmacist, but if your symptoms are severe, your doctor will probably advise stronger doses of H2 blockers, which are only available on prescription.
Proton pump inhibitors
Proton pump inhibitors block the production of acid and so allow the tissue that has been damaged by the acid to heal. They are usually very effective medicines for reflux.
Proton pump inhibitors include:
- esomeprazole (Nexium);
- lansoprazole (Zoton, Zopral);
- omeprazole (Losec, Acimax Maxor, Omepral);
- pantoprazole (Somac, Salpraz); and
- rabeprazole (Pariet, Prabez).
Side effects of PPIs can include headaches, diarrhoea and nausea.
Proton pump inhibitors that are available over-the-counter from the pharmacist, usually in a lower strength, include:
- omeprazole (Maxor Heatburn Relief);
- rabeprazole (Pariet 10); and
- pantoprazole (Salpraz Heartburn Relief, Somac Heartburn Relief, Suvacid Heartburn Relief).
Symptoms of gastro-oesophageal reflux should generally be treated with standard-dose proton pump inhibitors. Symptoms not responding to standard doses or recurring soon after stopping treatment should be investigated – see your doctor.
Surgery is usually only recommended for people with large hiatus hernias and people with symptoms that are not responding to other treatments. Surgery is also recommended for people who have complications from their hernia, such as obstruction of the oesophagus, severe pain, or bleeding.
Surgery is very rarely required for sliding hiatus hernias. Rolling hiatus hernias are much more likely to cause obstructions and strangulations than sliding hiatus hernias, and so are more likely to need corrective surgery.
Depending on the nature of your hernia, the surgery may involve:
- pulling the stomach back down into the abdomen under the diaphragm;
- tightening the opening in the diaphragm where the oesophagus passes through;
- strengthening the area where the oesophagus joins the stomach; and
- anchoring the stomach below the diaphragm.
The surgery may be either open or laparoscopic (‘keyhole’) surgery. There are possible side effects associated with both types of surgery – your doctor will be able to discuss the risks and benefits of surgery with you.
Always remember that if there is any change in your symptoms, or symptoms get worse, you should see your doctor.