What is it?

A hernia or herniation is the abnormal bulging, ballooning, or protrusion of a body structure –part of an organ or tissue area – through the normal boundaries that surround it.   A hiatal hernia occurs when the upper part of the stomach pushes up into the chest through a small opening in the diaphragm (the structure that separates the stomach from the chest, and that makes up part of the breathing muscles).  Normally, only the esophagus (food pipe) traverses this opening (or hiatus) of the diaphragm, but in hiatal hernia an abdominal organ (usually the stomach) has pushed or pocketed up into this area.

Hiatal hernia can occur in two forms:

• sliding hiatal hernia.  In this more common form, the connection of the stomach and esophagus slides up into the chest, causing part of the stomach to protrude into an elevated, herniated position.

• paraesophageal hernia.  In this form, part of the stomach pushes past the hiatus and bulges up next to the esophagus.

A hiatal hernia results in retention of acid and other stomach contents in the dislocated portion of the stomach. These acids and other substances can easily back up (reflux) into the esophagus.

 

What are causes and risk factors for hiatal hernias?

Esophageal abnormalities or a larger-than-normal opening of the diaphragm where the esophagus passes through to the stomach are both thought to predispose some people to this problem.  Many people age 50 and over have small hiatal hernias; however, hiatal hernias may affect people of all ages.

Sudden exertions of certain kinds that create abdominal pressure in people disposed to this condition, are thought to increase the likelihood of hiatal herniation, including:

• coughing;

• vomiting;

• straining;

• or sudden physical movements.

Obesity and pregnancy can also increase risk for this problem.

 

What are symptoms of abdominal hernias?

Most people who have hiatal hernias have no symptoms.  But the larger the hernia the more likely it is to cause symptoms, which can include chest pain that may mimic the sensations of a heart attack.

Sliding hiatal hernias usually occur in the presence of, cause, or exacerbate reflux disease.  The sphincter muscle at the juncture of the esophagus and the stomach, for example, is responsible for closing off back flow of stomach contents into the esophagus.  This type of hernia means that this sphincter is pushed at least partway out of position, removing the necessary structural pressure for it to prevent stomach acid from backing into the esophagus.  A hiatal hernia may also serve as a pouch, retaining gastric acid near the esophagus.

Most paraesophageal hernias do not produce symptoms.  If symptoms do occur, they are usually not reflux related but in the form of chest pain, or stomach other abdominal GI complaints.

Hiatal hernias may cause complications if the area of the stomach bulging through the diaphragm becomes strangulated (twisted in a way that cuts off blood supply to the protruding stomach tissue, a condition more likely in paraesophageal hernias) or causes an obstruction in the GI tract.  Symptoms of these urgent complications include severe pain in the chest or abdomen, difficulty swallowing, nausea, or vomiting.

 

How are abdominal hernias diagnosed?

In addition to taking a medical history and performing a physical examination, physicians may request the following diagnostic procedures in order to diagnose hiatal hernia:

• upper GI x-ray;

• or upper endoscopy.

 

How are abdominal hernias treated?

Most patients with hiatal hernias do not require any treatment.  For the majority who do require intervention, the treatment is for the accompanying gastroesophageal reflux disease.  Today, as a result of improved medications for reflux disease, doctors can use drug therapy to successfully manage a far greater percentage of patients who have otherwise symptomatic hiatal hernias. 

Hiatal hernias do require direct treatment, however, if the hernia is:

• in danger of becoming strangulated, a circumstance that applies primarily to paraesophogeal hernias, for which the medical team will usually recommend surgical repair to prevent any emergency complications from occurring later;

• or complicated by severe reflux disease that  causes significant symptoms – such as intense heartburn, or bleeding, ulcers, major inflammation, or narrowing of the esophagus – that have not responded to conservative treatment with medications or lifestyle changes.

In these cases, patients undergo surgery to correct the hiatal hernia.  Candidates for surgery also include younger patients with severe manifestations of reflux disease who want or need to avoid lifelong drug therapy, or patients who have respiratory conditions and who thus cannot risk aspiration pneumonia (which can occur when stomach contents are inhaled).