Health column: ‘So, Doc, do I have a hiatal hernia?’
As a gastroenterologist, I’ve learned that many patients misunderstand a common finding, the hiatal hernia.
There are two basic types of hiatal hernia. Ninety-five percent are of the sliding type, and 5 percent are of the para-esophageal type. Since the sliding type predominates, let’s focus on this form.
The sliding hiatal hernia consists of the lower esophagus and upper stomach sliding out of the abdominal cavity, through the gap (or the hiatus) in the diaphragm, into the chest. This internal hernia forms due to widening of the hiatus in the diaphragm and loosening of the ligament-like membranes that tether the lower esophagus and upper stomach to the diaphragm.
It is generally not obvious when and how a hiatal hernia formed in an individual, but events that increase the upward pressure in the abdominal cavity or the degenerative effects of aging on the diaphragm and securing membranes are presumed to play a role. A traumatic blow to the abdomen, vigorous retching or vomiting, severe coughing, abdominal straining or pregnancy may each contribute to the formation of a hiatal hernia.
Once a person has a hiatal hernia, they will have it for the rest of their lives unless surgery is performed to reverse it.
A hiatal hernia is important mainly because it often promotes acid reflux (i.e., gastroesophageal reflux disease, or GERD) by weakening the complex valve (known as the lower esophageal sphincter, or LES) that is situated near the junction of the esophagus and stomach. It is rare for a person to be aware of the presence of a hiatal hernia, apart from sensing symptoms of GERD, such as heartburn, regurgitation and/or chest pain. In fact, up to half of adults have a hiatal hernia, and most are unaffected and unaware of its presence. On the other hand, however, most (50-94 percent) people with GERD have a hiatal hernia. It is primarily because of GERD that a hiatal hernia is of importance.
This explains why the treatment of a hiatal hernia usually consists of treatment for GERD. And, since GERD usually responds well to dietary/lifestyle modification and use of acid-suppressing medication, only a small fraction of patients with a hiatal hernia require surgery.
Surgery involves re-establishing a competent valve near the junction of the esophagus and stomach by wrapping a portion of the upper stomach around the lower esophagus, tightening the gap (hiatus) in the diaphragm, and securing the upper stomach below the diaphragm. This procedure is performed for GERD symptoms that are not adequately controlled by diet and medication; in those unwilling or unable to stick with a daily, long-term regimen to control GERD; and occasionally, to treat an extremely large hiatal hernia, bleeding from the lining of a large hiatal hernia or acid reflux aggravating a pre-malignant condition known as Barrett’s esophagus.
A hiatal hernia is commonly found with endoscopy of the upper gastrointestinal tract, or with a barium upper GI series X-ray. It is often apparent in a CT scan or MRI scan of the chest or abdomen, and is even occasionally seen in a plain chest X-ray. However, testing for a hiatal hernia is necessary for only those people having persistent symptoms of GERD, pain in the chest or upper abdomen, or gastrointestinal bleeding.
I hope this sheds some light on the nature, importance and treatment of a hiatal hernia. Keep in mind that surgery for a hiatal hernia is seldom necessary.
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