Hernia Repair, Hiatal

Introduction

A hiatus hernia means that part of your stomach has squeezed through an opening in your diaphragm and into your chest.

The stomach normally sits in the abdomen, underneath a large, thin sheet of muscle called the diaphragm.

The opening in the diaphragm that the stomach can push through is called the hiatus. Your oesophagus (tube that carries food to your stomach) passes through the hiatus to reach your stomach.

How a hiatus hernia can cause heartburn

At the base of the oesophagus is a ring-like muscle, called a sphincter, which closes the lower oesophagus. This muscle acts as a one-way valve, preventing stomach contents from flowing upwards into the oesophagus.

When part of your stomach pokes through the hiatus, it prevents the muscle from closing the lower end of the oesophagus.

This means a hiatus hernia can cause highly irritating stomach contents, such as acid, to pass up into the oesophagus. It can cause heartburn and other problems, although in many cases a hiatus hernia causes no symptoms.

Who is affected

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’s a rare type of hiatus hernia that affects newborn babies.

What can be done

Medicines such as antacids can help to relieve symptoms of a hiatus hernia. Surgery may be an option in some cases if medication doesn’t work .

If the hiatus hernia isn’t causing symptoms, treatment is not necessary.

Symptoms of a hiatus hernia

In many cases, a hiatus hernia causes no symptoms and is discovered by chance during a routine investigation.

If you have symptoms, they can include:

Severe heartburn and gastro-oesophageal reflux disease (GORD), where stomach acid flows back into the oesophagus.
Deep burning chest pain, which may affect the shoulder blades. The pain is made worse by bending forward, straining or lying down. The pain may disturb sleep and can be so severe that it is mistaken for angina or a heart attack.
Difficulty swallowing due to constant acid irritation.

Other symptoms can include a croaky voice, sore throat, cough and symptoms of asthma.

Causes of a hiatus hernia

The exact cause of a hiatus hernia is unknown, but some people are more at risk of developing one.

A hiatus hernia is more common in people who are:

Over 50
Smokers
Overweight or obese
Pregnant

Pressure on the abdomen

It is thought that excessive coughing, vomiting, straining or sudden physical exertion can contribute towards a hiatus hernia as they create extreme pressure on the abdomen.

Obesity can also cause hiatus hernia because of the increased pressure on the abdomen.

Weakened diaphragm

It is estimated that one-third of people over 50 have a hiatus hernia, possibly because the diaphragm gets weaker with age, allowing part of the stomach to push through it.

Congenital problem

A rare type of hiatus hernia affects newborn babies. It occurs when the stomach or diaphragm doesn’t develop properly.

Diagnosing a hiatus hernia

A hiatus hernia may be diagnosed after an endoscopy or an X-ray – Dr. B C Shah will make an appointment for you to have this done in hospital.

An endoscopy is the most common test for a hiatus hernia. An endoscope (a long, tube-like viewing instrument that contains a video camera and light source) is passed down the oesophagus (gullet) into the stomach.

If you’re having an X-ray, you may swallow a watery paste made from barium sulphate. It’s a heavy, odourless powder that’s insoluble (doesn’t dissolve) and isn’t poisonous. It coats the inside of the stomach and makes it easier to see the digestive system when an X-ray is performed.

Both procedures allow the doctor to check for evidence of a hiatus hernia.

Treating a hiatus hernia

If your hiatus hernia doesn’t cause any symptoms, there’s no need for treatment.

If you have symptoms, antacid medicines and a change of lifestyle are the preferred treatments.

Treatment aims to prevent stomach acid from flowing back into the oesophagus, improve the clearance of food from the oesophagus (gullet) and reduce the amount of stomach acid that’s produced.

Antacid medicines

Antacid medicines can relieve some of the symptoms of hiatus hernia. Antacids come in liquid or tablet form and are swallowed or chewed. When they reach the oesophagus and stomach, they help to neutralise the acid (make it less acidic).

Antacid medicines don’t work for everyone. They’re not a long-term solution if symptoms persist and cause extreme pain and discomfort.

Alginates

Alginates contain a foaming agent, which forms a layer that floats on top of your stomach contents. This prevents stomach acid from flowing back into the oesophagus and protects your oesophagus lining.

Acid-suppressing medicines

Acid-suppressing medicines reduce the amount of acid produced by your stomach. They’re called histamine receptor blockers, or H2 antagonists, and include cimetidine, famotidine andranitidine.

Proton pump inhibitors

Proton pump inhibitors (PPIs) reduce the amount of acid produced by your stomach. They’re usually the first treatment for gastro-oesophageal reflux disease (GORD), which can be a symptom of hiatus hernia. Prescribed drugs include omeprazole,lansoprazole, rabeprazole and esomeprazole.

Motility stimulants

Motility stimulants, such as domperidone and metoclopramide, speed up the rate at which your stomach empties. They also improve the squeezing of the sphincter muscle, to help stop stomach contents being brought back up into your oesophagus. They can cause side effects, so only take them when needed.

Surgery

Surgery may be an option in some cases of hiatus hernia if medication doesn’t relieve your symptoms. Surgery may also be recommended for cases of GORD that do not respond to other treatments.

During surgery, the stomach is put back into the correct position and the diaphragm around the lower part of the oesophagus is tightened. Surgery is most commonly performed using laparoscopy (the least invasive technique, where several small incisions are made in your abdomen).

The operation isn’t complicated. Most people go home after an overnight stay.

Complications of a hiatus hernia

Ulceration and bleeding

Acid reflux (where stomach acid flows up into the oesophagus) may cause painful damage to the oesophagus lining. It can cause ulcers and, in some cases, bleeding. Loss of blood can lead to anaemia.

Strangulation

In rare cases, the hiatus hernia can become strangulated (knotted). This causes its blood supply to be cut off and requires emergency surgery.

Stricture

Severe and long-lasting inflammation (swelling) can cause scarring and narrowing of the oesophagus. This may cause pain and can affect your ability to swallow food. This is called a stricture.

Barrett’s oesophagus

Barrett’s oesophagus is a rare condition caused by long-standing acid reflux, where the cells lining the lower oesophagus change, increasing the risk of cancer of the oesophagus.

Cancer

There’s a very low risk of cancer of the oesophagus if you have long-term acid reflux.