Hiatus Hernia
A hiatus hernia, or
hiatal hernia, is when part of the stomach squeezes into the chest
through an opening in the diaphragm called the hiatus. The diaphragm is a
large, thin sheet of muscle located between the chest and the abdomen
(tummy).
Schematic diagram showing a Hiatus Hernia.
A hiatus hernia
itself rarely has any noticeable symptoms. However, it can cause a problem
called gastro-oesophageal reflux disease (GORD). GORD is when stomach
acid leaks into the oesophagus (the tube that carries food to the stomach).
It can occur if a hiatus hernia prevents the valve at the bottom of the
oesophagus from working properly.
Your oesophagus can
become severely irritated because it is not protected against stomach
acid. This may result in symptoms such as heartburn, chest pain, an
unpleasant sour taste in your mouth, and problems swallowing (dysphagia). You should see your doctor if you have frequent and severe symptoms of GORD.
Hiatus hernia can
affect anyone, but it's more common in women and people who are over 50,
overweight, pregnant or who smoke. It's estimated that a third of people over
50 have a hiatus hernia. There is also
a rare type of hiatus hernia that affects newborn babies.
It is not exactly
clear what causes hiatus hernia, but it may be the result of the diaphragm
becoming weak with age or pressure on the abdomen. Hiatus hernia
can occur in newborn babies if the stomach or diaphragm doesn't develop
properly.
There are two main
types of hiatus hernia:
- sliding hiatus
hernias – hernias that move up and down, in and out of the chest
area (more than 80% of hiatus hernias are this type)
- para-oesophageal hiatus
hernias – also called rolling hiatus hernias, this is where part of
the stomach pushes up through the hole in the diaphragm next to the
oesophagus (about 5-15% of hiatus hernias are this type).
Schematic diagram showing the two main types of hiatus hernia.
The type of hiatus
hernia can usually be diagnosed using an X-ray or an endoscopy, where a
long, tube-like instrument with a video camera and light source is used.
Treatment for sliding
hiatus hernia usually focuses on relieving the symptoms of GORD, such as
heartburn. Lifestyle changes and
medication are the preferred treatments. Surgery is usually only recommended as
an alternative to long-term medication or if other treatments have not worked.
Lifestyle
advice may include:
- eating smaller, more
frequent meals rather than three large meals a day
- avoiding lying down
(including going to bed) for three hours after eating or drinking
- removing any foods or drinks that make your symptoms worse from your diet.
If a hiatus hernia
is not causing any noticeable problems, it does not usually need to be treated. Para-oesophageal
hiatus hernias are repaired surgically if there is a risk of serious
complications.
It is rare for a
hiatus hernia to cause complications, but long-term damage to the
oesophagus caused by leaking stomach acid can lead to ulcers,
scarring and changes to the cells of the oesophagus, which can increase
your risk of oesophageal cancer.
Diagnosing a hiatus hernia
A hiatus hernia can usually be
diagnosed after an endoscopy or an X-ray. Your doctor will make an appointment for
you to have this done in hospital.
During
an endoscopy the inside of your body is directly examined using
an endoscope (a long, thin flexible tube that has a light source and video
camera at one end), which sends images to an external monitor. The endoscope will be
inserted into your mouth and down your throat to look for any problems. The
procedure is usually done while you are awake and you may be given a sedative
to help you to relax.
The barium
meal X-ray, also called the barium swallow test, is one of the most
effective ways of identifying a hiatus hernia. As part of the test
you will be asked to drink some barium solution. Barium is a non-toxic
chemical that shows up clearly on an X-ray. Once the barium moves
down into your digestive system a series of X-rays will be taken to identify
any problems.
If you need to have a
barium meal X-ray, you will not be able to eat or drink anything for at least
six hours before the procedure so that your stomach and duodenum (top of the
small intestine) are empty. You may be given an injection to relax the muscles
in your digestive system.
You will be given a
white, chalky liquid containing barium to drink while lying down. This means
your specialist will be able to see your stomach on an X-ray monitor more
easily, as well as any ulcers or abnormal growths. Your bed may be tipped
slightly during the test so that the barium fills all the areas of your
stomach.
A barium swallow
usually takes about 15 minutes to perform. Afterwards you will be able to eat
and drink as normal, although you may need to drink more water to help flush
the barium out of your system. You may feel slightly
sick after a barium meal X-ray and the barium may cause constipation. Your
stools may also be white for a few days afterwards as the barium passes
through your system.
Treatment
Treatment for a
hiatus hernia is usually only necessary if it is causing problems. In most cases, people
with a hiatus hernia only experience problems if the hernia
causes gastro-oesophageal reflux disease (GORD). GORD can cause symptoms
such as heartburn and an unpleasant taste in your mouth. Lifestyle changes and
medication are the preferred treatments, although surgery may be used as an
alternative to long-term medication or if other treatments are ineffective.
A number of
self-care techniques may help relieve symptoms of GORD caused by a hiatus
hernia. These include:
- eating smaller, more
frequent meals rather than three large meals a day
- avoiding lying down
(including going to bed) for at least three hours after eating or
drinking
- avoiding drinking during the
night
- removing certain foods from
your diet if you think they make your symptoms worse
- avoiding alcohol, caffeine,
chocolate, tomatoes, fatty foods, spicy foods and acidic food or
drinks (such as citrus fruit juice) if they make your symptoms worse
- avoiding bending over or
stooping, especially after eating or drinking
- raising the head of your bed
by around 20cm (8 inches) by placing a piece of wood or blocks under
it – do not use extra pillows because this may increase pressure on
your abdomen.
If you are
overweight, losing weight may help reduce the severity and frequency of
your symptoms. If you smoke,
consider stopping. Tobacco smoke can irritate your digestive system and may
make your symptoms worse.
A number of different
medications can be used to treat symptoms of hiatus hernia.
Antacid
medicines can relieve some of the symptoms of hiatus hernia. They
come in liquid or tablet form and can be swallowed or chewed. They help
neutralise stomach acid when they reach the oesophagus and stomach by
making it less acidic. However, antacid
medicines don't work for everyone. They are not a long-term solution if symptoms
persist or you are in extreme discomfort.
Antacids should not
be taken at the same time as other medicines because they can stop other
medicines from being properly absorbed by your body. They may also damage
the special coating on some types of tablets. Ask your Doctor or pharmacist for
advice.
Alginates are an
alternative medicine to antacids. They work by producing a protective coating
that shields the lining of your stomach and oesophagus from the effects of
stomach acid.
In some cases, a
medicine known as an H2-receptor antagonist (H2RA) may be recommended if a
hiatus hernia is causing GORD. Examples of H2RAs include
cimetidine, famotidine and ranitidine.
H2RAs block the
effects of the chemical histamine, which your body uses to produce
stomach acid. H2RAs therefore help reduce the amount of acid in your stomach. Side effects of H2RAs
are uncommon. However, possible side effects may include diarrhoea, headaches,
tiredness and a rash.
Some H2RAs are
available over the counter at pharmacies. These types of HR2As are taken in a
lower dosage than the ones available on prescription. You can ask your doctor or pharmacist
if you are not sure whether these medicines are suitable for you.
Your doctor may prescribe
a medication called a proton-pump inhibitor (PPI). PPIs work by reducing the
amount of acid produced by your stomach. Examples of the PPIs you may be
prescribed include omeprazole, lansoprazole, rabeprazole and esomeprazole. Most people tolerate
PPI well and side effects are uncommon. When they do occur they are usually
mild and may include headaches, diarrhoea, feeling sick, or constipation.
To minimise any side
effects, your doctor will prescribe the lowest possible dose of PPIs they think
will be effective. You should let your doctor know if the prescribed dose of PPIs
doesn't work. A stronger dose may be needed.
If your symptoms are
not responding to other forms of treatment, your doctor may prescribe a short-term
dose of a prokinetic. Examples of prokinetic medicines include domperidone and
metoclopramide. Prokinetics speed up
the emptying of your stomach, which means there is less opportunity for acid to
irritate your oesophagus.
A small number of
people who take prokinetics have what is known as extrapyramidal symptoms.
Extrapyramidal symptoms are a series of related side effects that affect your nervous
system and can include:
- muscle spasms
- problems opening your mouth
fully
- a tendency to stick your
tongue out of your mouth
- slurred speech
- abnormal changes in body
posture.
If you have the above
symptoms while taking prokinetics, stop taking them and contact your doctor or
out-of-hours doctor immediately. They may recommend you stop taking them. The
symptoms should stop within 24 hours of the medicine being withdrawn. Prokinetics are not
usually recommended for people under the age of 20 because of an increased risk
of extrapyramidal symptoms.
Surgery is usually
only recommended for a sliding hiatus hernia if the problem fails to respond to
lifestyle changes and medication. You may also wish to
consider surgery if you have persistent and troublesome symptoms but do not
want to take medication on a long-term basis.
Prior to surgery you
may need further investigations to check how well the oesophagus moves
(manometry) and how much acid is being refluxed (24-hour oesopageal pH
studies).
A procedure called a
laparoscopic nissen fundoplication (LNF) is one of the most common surgical
techniques used to treat GORD and sliding hiatus hernias. LNF is a type of
keyhole surgery that involves making a series of small cuts in your abdomen.
Carbon dioxide gas is used to inflate your abdomen to give the surgeon room to
work in.
Schematic diagram showing how a laparoscopic Nissen Fundoplication is performed.
During LNF, the
stomach is put back into the correct position and the diaphragm around the
lower part of the oesophagus is tightened. This should prevent any acid moving
back out of your stomach. LNF is carried out
under general anaesthetic, so you will not feel any pain or discomfort.
The surgery takes 60 to 90 minutes to complete.
After having LNF,
most people can leave hospital once they have recovered from the effects of the
general anaesthetic. This is usually within two to three days. Depending on the
type of job you do, you should be able to return to work within three to six
weeks. For the first six
weeks after surgery it is recommended you only eat soft food, such as mince,
mashed potatoes or soup. Avoid eating hard food that could get stuck at the
site of the surgery, such as toast, chicken or steak.
Schematic diagram showing the different stages of a Laparoscopic Hiatus Hernia Repair.
Common side effects of
LNF include difficulties swallowing (dysphagia), belching, bloating and
flatulence. These side effects
should resolve over the course of a few months. However, in about 1 in 100
cases they can be persistent. In such circumstances, further corrective surgery
may be required.
If you have
a para-oesophageal hiatus hernia, where the stomach pushes up through the
hole in the diaphragm next to the oesophagus, surgery may be recommended to
reduce the risk of the hernia becoming strangulated.
Complications
Complications of a hiatus hernia
Complications from a hiatus hernia
are rare, but they can be serious. Hiatus hernias that
slide in and out of the chest area (sliding hiatus hernias) can
cause gastro-oesophageal reflux disease (GORD). This is where stomach acid
leaks into the oesophagus (gullet). This can damage the oesophagus, increasing
the risk of the problems described below.
Damage to the lining
of the oesophagus (oesophagitis) caused by stomach acid can lead to the
formation of ulcers. The ulcers can bleed, causing pain and making swallowing
difficult.
Ulcers can usually be
successfully treated by controlling the underlying symptoms of GORD. In most
cases, over-the-counter medicines called antacids or alginates are used to
treat the condition.
Repeated damage to
the lining of your oesophagus can lead to the formation of scar tissue. If the
scar tissue is allowed to build up, it can cause your oesophagus to become
narrowed. This is known as oesophageal stricture. An oesophageal
stricture can make swallowing food difficult and painful. Oesophageal
strictures can be treated by using a tiny balloon to dilate (widen) the
oesophagus. This procedure is usually carried out under a local anaesthetic.
Repeated damage to
the oesophagus can also lead to changes in the cells lining your lower
oesophagus. This is a condition known as Barrett's oesophagus. Barrett's oesophagus
does not usually cause noticeable symptoms other than those associated with
GORD. However, Barrett's
oesophagus can increase your risk of developing oesophageal cancer.
In some cases, a
hiatus hernia causes part of the stomach to push up next to the oesophagus.
This is known as a para-oesophageal hiatus hernia. GORD does not usually occur
in these cases, but there is a risk of the hernia becoming strangulated. Strangulation occurs
when the hernia becomes knotted and the blood supply to the area is cut off.
Emergency surgery is usually required to correct the problem.
Source: NHS Choices.
Source: NHS Choices.
