Schematic diagram showing hiatal hernia.
A hiatus hernia, or hiatal hernia, is when
part of the stomach squeezes up into the chest through an opening
("hiatus") in the diaphragm. The diaphragm is a large, thin sheet of
muscle between the chest and the abdomen (tummy).
Hiatus
hernia and heartburn
A hiatus hernia itself rarely has any
noticeable symptoms. However, it can cause a problem called gastro-oesophageal reflux disease (GORD). GORD is where 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's not protected against stomach acid. This can cause symptoms such
as heartburn, chest pain, an unpleasant sour taste
in your mouth, and swallowing problems (dysphagia). You should see your doctor/ GP if you have frequent and
severe symptoms of GORD.
What
causes a hiatus hernia?
It's 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 sometimes occur in newborn babies
if the stomach or diaphragm doesn't develop properly.
Who is
affected
Hiatus hernia can affect anyone, but it's more
common in people who are:
- over
50 years of age
- overweight
- pregnant.
It is 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, which is caused by a congenital defect of the
stomach or diaphragm. Congenital means that it is present from birth.
Types of
hiatus hernia
There are two main types of hiatus hernia. They
are:
- sliding
hiatus hernias – hernias
that move up and down, in and out of the chest area (more than 80% of
hiatus hernias are of this type)
- para-oesophageal
hiatus hernias – also
called rolling hiatus hernias, where part of the stomach pushes up through
the hole in the diaphragm next to the oesophagus (about 5-15% of hiatus
hernias are of this type).
These pages mainly focus on sliding hiatus
hernias. They can usually be diagnosed using an X-ray or an endoscopy, where a long, thin flexible tube
with a light and video camera at one end is used to examine the inside of the
body.
Treating
a hiatus hernia
Treatment for a 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 haven't 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 from your diet that make your symptoms worse.
If a hiatus hernia is not causing any noticeable
problems, it does not usually need to be treated. Surgery is used to repair a para-oesophageal hiatus
hernia if there's a risk of serious complications.
Further
problems
It's 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 a
gastroscopy or X-ray.
Gastroscopy
A gastroscopy is a procedure where
the inside of your body is examined using a gastroscope (a long, thin
flexible tube with a light and video camera at one end), which sends images to
an external monitor.
The gastroscope will be inserted into your mouth
and down your throat, and will be used to help identify any problems. The
procedure may be carried out using a local anaesthetic or a sedative to
help you relax.
Barium
meal X-ray
The barium meal X-ray, also called the barium swallow test,
is an effective way 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 won't
be able to eat or drink anything for at least six hours before the procedure,
so that your stomach and duodenum (the 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 will allow the specialist 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.
Treating a hiatus hernia
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.
Lifestyle
changes
There are several things you can do yourself to
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, particularly 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; don't use extra pillows, because this may increase
pressure on your abdomen.
If you are overweight, losing weight may help to reduce the
severity and frequency of your symptoms. If you smoke, you should try to give up. Tobacco
smoke can irritate your digestive system and may make your symptoms worse.
Medication
A number of different medications can be used to
treat symptoms of hiatus hernia. These are described below.
Antacids
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 to neutralise stomach acid
when they reach the oesophagus and stomach by making it less acidic.
However, antacid medicines do not work for everyone.
They are not a long-term solution if symptoms persist or you're 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 GP or pharmacist for advice.
Alginates
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.
H2-receptor
antagonists
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 (PepcidTwo) and
ranitidine.
H2RAs block the effects of the chemical histamine,
which your body uses to produce stomach acid. H2RAs therefore help to
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 must ask your GP or pharmacist if you are not
sure whether these medicines are suitable for you.
Proton-pump
inhibitors (PPIs)
Your GP 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 PPIs well and side effects are
uncommon. When they do occur, they're usually mild and can include headaches,
diarrhoea, feeling sick or constipation.
To minimise any side effects, your GP will
prescribe the lowest possible dose of PPIs they think will be effective. You
should let your GP know if the prescribed dose of PPIs doesn't work. A stronger
dose may be needed.
Surgery
Surgery is usually only recommended for a sliding
hiatus hernia (hernias that move up and down, in and out of the chest
area) if the problem fails to respond to lifestyle changes and medication.
You may also want to consider surgery if you have
persistent and troublesome symptoms, but don't 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).
Laparoscopic
nissen fundoplication (LNF)
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.
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 won't feel
any pain or discomfort. The surgery takes 60 to 90 minutes to complete. After having LNF, you should be able to leave
hospital after you've 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's
recommended that 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.
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.
Schematic diagram showing Nissen Fundoplication.
Para-oesophageal
hiatus hernia
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 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.
Oesophageal
ulcers
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.
Oesophageal
stricture
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 using a tiny
balloon to dilate (widen) the oesophagus. This procedure is usually carried out
under a local anaesthetic.
Barrett's
oesophagus and cancer
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 doesn't usually cause
noticeable symptoms, other than those associated with GORD. However, Barrett's
oesophagus can increase your risk of developing oesophageal cancer.
If you have persistent reflux symptoms for more
than three weeks, you should talk to your GP because you may need some
investigations.
Strangulated
hernia
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's 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