Medical Minute – Hiatal Hernias

By: Dr. James Lee

Last week we discussed GERD, this week we will discuss one of the leading causes of GERD. Hiatal hernia describes a condition in which a portion of the stomach protrudes through the diaphragm into the chest. The diaphragm is the muscle that allows us to breath and separates the chest cavity from the abdominal cavity. In the back center of the diaphragm is an opening called a hiatus which normally allows major blood vessels, esophagus, and some other structures to pass through the diaphragm normally.

There are two types of hiatal hernias: sliding and paraesophageal. Paraesophageal hernias are uncommon and are more likely to require surgery due to the risk of twisting of the stomach and compromising the blood supply. For this article, we will be discussing the sliding type hiatal hernia which represents 95% of all hiatal hernias. The incidence of hiatal hernia increases with age. Approximately 55-60% of individuals over the age of 50 have hiatal hernias. It is more common in women than men, perhaps due to the increased intrabdominal pressure that results during pregnancy. Other risk factors include obesity, COPD, constipation, and prior trauma.

The primary symptoms associated with hiatal hernias are the same as those for GERD including heartburn and indigestion. Sometimes with more advanced disease, regurgitation and trouble swallowing can be seen. Some patients with more advanced disease will also present with asthma or chronic cough if the reflux is severe enough to cause airway irritation.

The reason patients with hiatal hernias have GERD has to do with the differences between the abdominal and thoracic cavities. The abdomen has positive pressure. That is the contents of the abdominal cavity put pressure on the portion of the esophagus that is normally located in the abdominal cavity. This compresses the esophagus and helps prevent material inside the stomach going back into the esophagus. In the thoracic cavity, there is negative pressure, or a vacuum. The diaphragm acts as a bellows, creating a vacuum that allows us to inhale air into our lungs, then relaxes to allow us to exhale. When the end of the esophagus and a portion of the stomach is in the chest, they too are subject to the negative pressure vacuum and stomach contents can be pulled up into the esophagus.

Diagnosis of hiatal hernia is done primarily with endoscopy, passage of a scope through the mouth into the stomach. Other tests that can see hernias include CT scans and contrasted x-rays, but these do not allow the same degree of evaluation as endoscopy. Endoscopy can distinguish paraesophageal and sliding type hernias.

Many people who have hiatal hernias are not even aware of the condition. The main symptoms are GERD symptoms and treatment is with acid reduction and lifestyle changes like those discussed last weeks article on GERD. These include weight loss, avoidance of caffeine, nicotine, alcohol, chocolate, and peppermints, as well as avoiding eating within 4 hours of lying down and sleeping with the head of the bed elevated. For most, this results in the relief of GERD symptoms and no further treatment of the hiatal hernia is necessary.

Surgical treatment of hiatal hernia is primarily for those patients with persistent symptoms despite medical treatment, or those who have severe injury to their esophagus like ulcer, strictures, or a condition called Barrett’s esophagus. Barrett’s esophagus is a condition where normal intestinal cells migrate to the esophagus to protect it from continued acid reflux. The issue with Barrett’s is that these cells are unstable and can become abnormal, increasing the risk of esophageal cancer.

Often further tests are done before surgery to ensure that the esophagus is functioning properly and that the symptoms relate to periods of high acid content in the esophagus. The surgery to treat hiatal hernia is called fundoplication and can frequently be done laparoscopically through small incisions. This involves three parts: the stomach and end of the esophagus are brought back into the abdomen, the defect in the hiatus is repaired, and the upper part of the stomach is wrapped around the end of the esophagus.

If you have GERD and continue to have symptoms despite treatment, have a discussion with your physician about other treatment options.

Dr. James Lee serves as the Coroner of Winn Parish. He is a General Surgeon and Surgical Oncologist who has been practicing in Winnfield for over ten years. Dr. Lee attended the University of Colorado for his medical degree. He completed his residency in Surgery at the University of Oklahoma before completing a fellowship in Surgical Oncology and Endoscopy at Roswell Park Cancer Institute in Buffalo, NY. Dr. Lee and his wife Scarlett live in Winnfield with their son and are active in the community.