Hernia and acid reflux

Connecting the Dots: Understanding the Link Between Hiatal Hernia and GERD

Describing the relationship between hiatal hernias and gastroesophageal reflux disease (GERD), doctors say, is like explaining the “chicken or the egg” scenario.

“There is a debate about whether one condition causes another or if one is associated with the other,” says Jennifer Castro, MD, a general and laparoscopic surgeon at the Hampton VA Medical Center. ”People can have a hiatal hernia without GERD. And others can have GERD without a hiatal hernia. If they have both, it’s uncertain whether the hiatal hernia caused GERD.”

According to the book, Hiatal Hernia Surgery, published in August 2017, suggests that the relationship between these conditions is relatively intertwined and has clinical significance. In fact, people with a hiatal hernia may be more likely to have GERD. There is also a close relationship between hiatal hernia size and incidence of GERD.

Leslie Memsic, MD, a surgical oncologist who specializes in breast cancer and hernia treatment at the Bedford Breast Center in Beverly Hills, says some studies suggest that chronic acid reflux actually leads to weakening of the sphincter and the development of a hiatal hernia. “But, more commonly, a large hiatal hernia is thought to contribute to GERD,” Dr. Memsic says.

Is It a Hiatal Hernia, GERD, or Both?

A hiatal hernia can occur from long-lasting GERD or GERD could be a symptom of a hiatal hernia, according to the Cleveland Clinic. When GERD progresses, it can cause the lower esophageal sphincter to lose its function, which may cause a hiatal hernia, according to RefluxMD. A hiatal hernia could also worsen GERD symptoms. So the bottom line is, you could have one of these conditions or they can coexist. Here’s how you can differentiate the two:

A hiatal hernia occurs when the hole in the diaphragm (hiatus) through which food and liquids pass from the esophagus into the stomach enlarges. This facilitates acid reflux and can cause the stomach to slide upward into the chest, says Dr. Castro. This condition in severe cases can lead to more serious complications such as obstruction or strangulation of the stomach, says Memsic.

What could put you at risk? Weakened muscles in the diaphragm can allow the stomach to move freely into the hiatus, or inherited structural abnormalities in the diaphragm can cause a congenital hiatal hernia, which presents at birth. Other causes include excess pressure on the abdomen or muscle strain due to heavy coughing, constipation, or intense physical exertion. Pregnancy and obesity are also risk factors for hiatal hernia, according to the Mayo Clinic.

GERD is very common and typically presents as heartburn, a condition that affects more than 40 percent of Americans. GERD occurs when “stomach contents reflux back into the esophagus, causing issues such as heartburn, regurgitation, difficulty swallowing. And even chest pain is the presence of stomach contents in the esophagus,” says Castro.

RELATED: What’s the Difference Between Acid Reflux and GERD?

Small hiatal hernias don’t typically present signs or symptoms, according to the Mayo Clinic, but those with a more severe hernia may experience:

  • Heartburn
  • Regurgitation of food or liquids into the mouth
  • Backflow of stomach acid into the esophagus (acid reflux)
  • Difficulty swallowing
  • Chest or abdominal pain
  • Shortness of breath
  • Vomiting of blood or passing of black stools, which may indicate gastrointestinal bleeding

In serious cases, a hiatal hernia can cause bleeding, strangulation, and perforation of the stomach, says Castro.

Symptoms of GERD, according to the Mayo Clinic, include:

  • A burning sensation in your chest (heartburn), usually after eating, which might be worse at night
  • Chest pain
  • Difficulty swallowing
  • Regurgitation of food or sour liquid
  • Sensation of a lump in your throat

According to the Cleveland Clinic, many people actually have a hiatal hernia without having GERD and others have GERD without having a hiatal hernia. Most people with a hiatal hernia don’t have any symptoms. If you have a hiatal hernia that presents with frequent and more severe symptoms, this could be an indicator that you have both conditions (hiatal hernia and GERD), according to an article published by the University of Wisconsin’s School of Medicine and Public Health.

How to Diagnose a Hiatal Hernia and GERD

There are three major tests to diagnose a hiatal hernia, according to the Mayo Clinic.

  1. X-ray of your upper digestive system: Patients drink a chalky liquid that coats and fills the inside of the digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach, and upper intestine.
  2. Upper endoscopy: A procedure in which a doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat, to examine the inside of your esophagus and stomach and check for inflammation
  3. Esophageal manometry: A test that measures the rhythmic muscle contractions in your esophagus when you swallow and measures the coordination and force exerted by the muscles of your esophagus

Like a hiatal hernia, GERD can be diagnosed by performing an upper endoscopy, an esophageal manometry, or an X-ray of your upper digestive system, according to the Mayo Clinic. Patients can also be diagnosed with GERD through an ambulatory acid (pH) probe test, in which a monitor is placed in your esophagus to identify when and how long stomach acid regurgitates there.

Medical Treatment and Surgical Options to Deal With Hiatal Hernia and GERD

“The majority of patients with hiatal hernia that have symptoms of GERD can be managed by lifestyle changes and medication,” says Memsic, adding that less than 20 percent of patients with hiatal hernia will require surgery due to risk of strangulation, obstruction, or perforation.

“For straightforward GERD symptoms, lifestyle modification and medicines like the proton pump inhibitors are the mainstays of treatment. We also recommend avoiding heavy meals, to remain upright for at least three hours after eating, and to elevate the head of the bed to prevent reflux while sleeping,” says Castro.

Patients with GERD should also avoid food and drink that can increase reflux such as coffee, chocolate, carbonated beverages, alcohol, citrus and acidic foods, onions, mint, fatty foods, spicy foods, and garlic, says Castro. Foods such as yogurt, ginger, and aloe vera can help to soothe the stomach, says Memsic.

A symptomatic hiatal hernia can be treated with lifestyle changes, dietary changes, and medication, including antacids, H2 blockers, and proton pump inhibitors. It is important for proton pump inhibitors to be given under the care of a physician, as they can interfere with calcium and aggravate cardiac issues, says Memsic.

Patients with more severe hiatal hernia and GERD symptoms may need surgery. Laparoscopic (minimally invasive) repair of a hiatal hernia and GERD, called Nissen fundoplication, is considered to be 90 percent effective in most patient populations, according to the Cleveland Clinic. The surgery strengthens the lower esophageal sphincter and requires general anesthesia and a one-day stay in the hospital. After the operation, patients will no longer need to take antacid medication.

Patients who have persisting symptoms that don’t improve after implementing lifestyle changes and taking medical treatment should consult a doctor, says Memsic, adding that surgery should be a last resort.

Gastroesophageal Reflux Disease, Hiatal Hernia and Heartburn

Gastroesophageal reflux disease (GERD) is a digestive disorder that affects the lower esophageal sphincter (LES)–the muscle connecting the esophagus with the stomach. Many people, including pregnant women, suffer from heartburn or acid indigestion caused by GERD. Doctors believe that some people suffer from GERD due to a condition called hiatal hernia. In most cases, heartburn can be relieved through diet and lifestyle changes; however, some people may require medication or surgery. This fact sheet provides information on GERD-its causes, symptoms, treatment, and long-term complications.

What Is Gastroesophageal Reflux?

Gastroesophageal refers to the stomach and esophagus. Reflux means to flow back or return. Therefore, gastroesophageal reflux is the return of the stomach’s contents back up into the esophagus.
In normal digestion, the LES opens to allow food to pass into the stomach and closes to prevent food and acidic stomach juices from flowing back into the esophagus. Gastroesophageal reflux occurs when the LES is weak or relaxes inappropriately allowing the stomach’s contents to flow up into the esophagus. Figure 1 shows the location of the LES between the esophagus and the stomach.

The severity of GERD depends on LES dysfunction as well as the type and amount of fluid brought up from the stomach and the neutralizing effect of saliva.

What Is the Role of Hiatal Hernia?

Some doctors believe a hiatal hernia may weaken the LES and cause reflux. Hiatal hernia occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm (diaphragmatic hiatus). The diaphragm is the muscle separating the stomach from the chest. Recent studies show that the opening in the diaphragm acts as an additional sphincter around the lower end of the esophagus. Studies also show that hiatal hernia results in retention of acid and other contents above this opening. These substances can reflux easily into the esophagus.
Coughing, vomiting, straining, or sudden physical exertion can cause increased pressure in the abdomen resulting in hiatal hernia. Obesity and pregnancy also contribute to this condition. Many otherwise healthy people age 50 and over have a small hiatal hernia. Although considered a condition of middle age, hiatal hernias affect people of all ages.

Hiatal hernias usually do not require treatment. However, treatment may be necessary if the hernia is in danger of becoming strangulated (twisted in a way that cuts off blood supply, i.e., paraesophageal hernia) or is complicated by severe GERD or esophagitis (inflammation of the esophagus). The doctor may perform surgery to reduce the size of the hernia or to prevent strangulation.

What Other Factors Contribute to GERD?

Dietary and lifestyle choices may contribute to GERD. Certain foods and beverages, including chocolate, peppermint, fried or fatty foods, coffee, or alcoholic beverages, may weaken the LES causing reflux and heartburn. Studies show that cigarette smoking relaxes the LES. Obesity and pregnancy can also cause GERD.

What Does Heartburn Feel Like?

Heartburn, also called acid indigestion, is the most common symptom of GERD and usually feels like a burning chest pain beginning behind the breastbone and moving upward to the neck and throat. Many people say it feels like food is coming back into the mouth leaving an acid or bitter taste.
The burning, pressure, or pain of heartburn can last as long as 2 hours and is often worse after eating. Lying down or bending over can also result in heartburn. Many people obtain relief by standing upright or by taking an antacid that clears acid out of the esophagus.

Heartburn pain can be mistaken for the pain associated with heart disease or a heart attack, but there are differences. Exercise may aggravate pain resulting from heart disease, and rest may relieve the pain. Heartburn pain is less likely to be associated with physical activity.

How Common Is Heartburn?

More than 60 million American adults experience Gerd and heartburn at least once a month, and about 25 million adults suffer daily from heartburn. Twenty-five percent of pregnant women experience daily heartburn, and more than 50 percent have occasional distress. Recent studies show that GERD in infants and children is more common than previously recognized and may produce recurrent vomiting, coughing and other respiratory problems, or failure to thrive.

What Is the Treatment for GERD?

Doctors recommend lifestyle and dietary changes for most people with GERD. Treatment aims at decreasing the amount of reflux or reducing damage to the lining of the esophagus from refluxed materials.
Avoiding foods and beverages that can weaken the LES is recommended. These foods include chocolate, peppermint, fatty foods, coffee, and alcoholic beverages. Foods and beverages that can irritate a damaged esophageal lining, such as citrus fruits and juices, tomato products, and pepper, should also be avoided.

Decreasing the size of portions at mealtime may also help control symptoms. Eating meals at least 2 to 3 hours before bedtime may lessen reflux by allowing the acid in the stomach to decrease and the stomach to empty partially. In addition, being overweight often worsens symptoms. Many overweight people find relief when they lose weight.

Cigarette smoking weakens the LES. Therefore, stopping smoking is important to reduce GERD symptoms.

Elevating the head of the bed on 6-inch blocks or sleeping on a specially designed wedge reduces heartburn by allowing gravity to minimize reflux of stomach contents into the esophagus.

Antacids taken regularly can neutralize acid in the esophagus and stomach and stop heartburn. Many people find that nonprescription antacids provide temporary or partial relief. An antacid combined with a foaming agent such as alginic acid helps some people. These compounds are believed to form a foam barrier on top of the stomach that prevents acid reflux from occuring.

Long-term use of antacids, however, can result in side effects, including diarrhea, altered calcium metabolism (a change in the way the body breaks down and uses calcium), and buildup of magnesium in the body. Too much magnesium can be serious for patients with kidney disease. If antacids are needed for more than 3 weeks, a doctor should be consulted.

For chronic reflux and heartburn, the doctor may prescribe medications to reduce acid in the stomach. These medicines include H2 blockers, which inhibit acid secretion in the stomach. Currently, four H2 blockers are available: cimetidine, famotidine, nizatidine, and ranitidine. Another type of drug, the proton pump (or acid pump) inhibitor omeprazole inhibits an enzyme (a protein in the acid-producing cells of the stomach) necessary for acid secretion. The acid pump inhibitor lansoprazole is currently under investigation as a new treatment for GERD.

Other approaches to therapy will increase the strength of the LES and quicken emptying of stomach contents with motility drugs that act on the upper gastrointestinal (GI) tract. These drugs include cisapride, bethanechol, and metoclopramide.

Tips To Control Heartburn

  • Avoid foods and beverages that affect LES pressure or irritate the esophagus lining, including fried and fatty foods, peppermint, chocolate, alcohol, coffee, citrus fruit and juices, and tomato products.
  • Lose weight if overweight.
  • Stop smoking.
  • Elevate the head of the bed 6 inches.
  • Avoid lying down 2 to 3 hours after eating.
  • Take an antacid.

What If Symptoms Persist?

People with severe, chronic esophageal reflux or with symptoms not relieved by the treatment described above may need more complete diagnostic evaluation. Doctors use a variety of tests and procedures to examine a patient with chronic heartburn.
An upper GI series may be performed during the early phase of testing. This test is a special x-ray that shows the esophagus, stomach, and duodenum (the upper part of the small intestine). While an upper GI series provides limited information about possible reflux, it is used to rule out other diagnoses, such as peptic ulcers.

Endoscopy is an important procedure for individuals with chronic GERD. By placing a small lighted tube with a tiny video camera on the end (endoscope) into the esophagus, the doctor may see inflammation or irritation of the tissue lining the esophagus (esophagitis). If the findings of the endoscopy are abnormal or questionable, biopsy (removing a small sample of tissue) from the lining of the esophagus may be helpful.

The Bernstein test (dripping a mild acid through a tube placed in the mid-esophagus) is often performed as part of a complete evaluation. This test attempts to confirm that the symptoms result from acid in the esophagus. Esophageal manometric studies-pressure measurements of the esophagus-occasionally help identify critically low pressure in the LES or abnormalities in esophageal muscle contraction.

For patients in whom diagnosis is difficult, doctors may measure the acid levels inside the esophagus through pH testing. Testing pH monitors the acidity level of the esophagus and symptoms during meals, activity, and sleep. Newer techniques of long-term pH monitoring are improving diagnostic capability in this area.

Does GERD Require Surgery?

A small number of people with GERD may need surgery because of severe reflux and poor response to medical treatment. Fundoplication is a surgical procedure that increases pressure in the lower esophagus. However, surgery should not be considered until all other measures have been tried.

What Are the Complications of Long-Term GERD?

Sometimes GERD results in serious complications. Esophagitis can occur as a result of too much stomach acid in the esophagus. Esophagitis may cause esophageal bleeding or ulcers. In addition, a narrowing or stricture of the esophagus may occur from chronic scarring. Some people develop a condition known as Barrett’s esophagus, which is severe damage to the skin-like lining of the esophagus. Doctors believe this condition may be a precursor to esophageal cancer.
Conclusion Although GERD can limit daily activities and productivity, it is rarely life-threatening. With an understanding of the causes and proper treatment most people will find relief.
Additional Readings Cramer T. A burning question: When do you need an antacid? FDA Consumer 1992; 26(1): 19-22. This article for consumers provides general information about antacids.
Larson DE, Editor-in-chief. Mayo Clinic Family Health Book. New York: William Morrow and Company, Inc., 1990. This general medical guide includes sections about esophageal reflux and hiatal hernia.

Richter JE. Why does surgery work for GERD? Practical Gastroenterology 1993; XVII(10): 10-18. This article for physicians describes antireflux surgery.

Sutherland JE. Gastroesophageal reflux disease: when antacids aren’t enough. Postgraduate Medicine 1991; 89(7): 45-53. This article for primary care physicians provides guidelines to determine if a patient has reflux disease and offers treatment methods.

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The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health under the U.S. Public Health Service. Established in 1980, the clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. NDDIC answers inquiries; develops, reviews, and distributes publications; and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

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What is a hiatal hernia?

A hiatal hernia occurs when part of the stomach, which normally resides in the abdomen moves upward through an enlarged opening in the diaphragm into the chest cavity. This type of a hiatal hernia is called a sliding hiatal hernia. While there are other types of hiatal hernias, this is the type most commonly associated with GERD and is the focus of this article.

The esophagus normally passes through a rather small opening in the diaphragm (the muscular structure separating the chest or thorax from the abdomen) to join the stomach in the abdomen. If this opening, which is called the hiatus, enlarges or dilates, it becomes large enough to allow a small or even large part of the stomach to pass through it into the chest. This can represent only a tiny amount of the upper stomach (as little as 2 or 3 centimeters-less than 1 inch), or a larger portion of the upper stomach; in extreme cases, almost the entire stomach comes to reside in the chest cavity instead of the abdomen where it belongs.

How is a hiatal hernia is diagnosed?

A hiatal hernia is diagnosed by looking at the anatomy of the esophagus via tests such as upper endoscopy or barium UGI studies. The diagnosis of GERD usually requires tests that look at the amount of acid reaching the esophagus, such as a pH study.

What you should know if you’ve been diagnosed with a hiatal hernia

Several things are essential to know about hiatal hernias in order to interpret and clarify what you may have been told by your physician or even read elsewhere.

  1. The term hiatal hernia and hiatus hernia are used interchangeably and mean exactly the same thing.
  2. Hiatal hernias are extremely common. In fact, by age 50, about 50% of individuals have at least a small hiatal hernia.
  3. Hiatal hernias, particularly small ones are usually asymptomatic and you would never know you have one.
  4. The presence of a hiatal hernia does not necessarily mean you have gastroesophageal reflux (GERD). However, a significant misunderstanding often occurs over this terminology. If you tell a physician that you have heartburn, the reply is often, “You may have a hiatal hernia.” They use the words “hiatal hernia” to mean GERD. This is incorrect and often creates confusion and a misunderstanding on the part of a patient. The reply should be that “You may have GERD.” The terms GERD and hiatal hernia are used in a way that suggests they are the same thing. Not all patients with GERD have a hiatal hernia and not all patients with a hiatal hernia have GERD! A hiatal hernia simply describes a very common anatomic abnormality, often with no consequences.

What is the relationship between a hiatal hernia and GERD?

Hiatal hernia as a consequence of longstanding GERD

GERD is a disease that progresses through various stages over periods of years, and a hiatal hernia can be a consequence of longstanding GERD. As the disease progresses, the lower esophageal sphincter (LES) loses its function. It cannot “squeeze” and function as a barrier to reflux. As this happens, the lower esophagus at the site of the LES dilates and the shape of the upper stomach is altered. The result is the enlargement of the opening in the diaphragm discussed above, leaving room for the top of the stomach to move upward into the chest. In this case, a hiatal hernia is a consequence of longstanding GERD. In addition, due to the difference in pressure between the chest cavity and the abdomen, movement of the stomach and lower esophagus upward causes an already poorly functioning LES to get even worse. A hernia makes the preexisting “bad” valve worse and consequently, GERD symptoms worsen.

A hiatal hernia itself causes symptoms of GERD

Another situation is also seen. If a person has a large hiatal hernia, they can have symptoms of GERD such as heartburn, but they can also have symptoms just from the distorted anatomy in having the wrong organ (stomach) in the wrong place (chest instead of abdomen). These symptoms can include chest pressure and pain, back pain, quickly getting full while eating, and others. A hernia itself, rather than GERD (which may or may not be present), causes these symptoms.

Hiatal hernia without GERD

There are several other causes of a hiatal hernia, but if the LES is functioning normally, there is no GERD. “Normal” anatomy is altered (a hernia), but there is no disease (GERD).

Hiatal hernia is not synonymous with GERD

Although it is present in many patients with GERD and often makes GERD symptoms worse, a hiatal hernia is not synonymous with GERD. Small hiatal hernias are extremely common and are usually asymptomatic. “Mechanical” symptoms can be caused by a large hernia, which may or may not be accompanied by GERD symptoms. How a hiatal hernia is treated depends largely on which of the above situations exist.

Doctors Cured My Heartburn After Finding a Hernia I Did Not Know I Had

Heartburn-Easing Foods That Fight GERD

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My doctor at first mentioned it could be irritable bowel syndrome (IBS), and I was really hoping it wasn’t IBS. Doctors rarely recommend a surgical repair of a hiatal hernia; instead they suggest you treat the symptoms of acid reflux.

I started taking prescription proton-pump inhibitors, which are medications that reduce the amount of acid in the stomach. It felt like I tried every one on the market, and nothing helped. My condition had escalated to the point that I would have acid reflux when I drank a glass of water.

GERD surgery worked for me
I began researching GERD surgery and found there was a doctor here in Houston who was doing a procedure called plication. In plication, pleats are used to strengthen the lower esophageal sphincter, the valve between the esophagus and stomach. This helps keep stomach acid out of the esophagus.

My insurance company considers plication to be experimental, so I knew it wouldn’t be covered. But I decided to find out if I could be a candidate for the operation anyway. I knew there was risks involved—I could have gone through the whole procedure and the symptoms could stay the same—but I was at the point that I was so miserable I was willing to take that risk.

I did some online research looking for people who had undergone plication surgery. I found one woman whose GERD caused her to hiccup nonstop whenever she ate anything. On the day of one of her children’s weddings she didn’t eat all day so she wouldn’t hiccup! But she had the procedure and was completely cured, so that gave me more courage to go ahead with my own plication.

I had the procedure, which was performed during an endoscopy (I didn’t have any incisions), in November 2007. It was an incredible success. I have had no problems related to GERD since. It has absolutely changed my life. I could have had my insurance company pay for stomach acid—suppressing drugs for the rest of my life, but I couldn’t keep going with my life like that—I was that miserable. It was approximately $4,000 out of pocket for my family but, for me, it is the best money I have ever spent.

Having this surgery gave me my back a normal life. I’m still careful about what I eat, but I’m so glad to have tomatoes back in my diet—especially being of Sicilian descent—and I can happily enjoy a good cup of coffee! I have not had any reflux symptoms since the plication.

It was a gamble because some people have the surgery and see no benefit, but I am now 100% cured. I couldn’t feel luckier.

Hiatus hernia

Treatment for a hiatus hernia is usually only necessary if it’s 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 3 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’re 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.

Read about stopping smoking.

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 don’t work for everyone. They’re not a long-term solution if symptoms persist or you’re in extreme discomfort.

Antacids shouldn’t 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. Ask your GP or pharmacist if you’re 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 2 to 3 days. Depending on the type of job you do, you should be able to return to work within 3 to 6 weeks.

For the first 6 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.

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 (see complications of a hiatus hernia for more information).

Hiatal Hernia: Symptoms, Causes, Diagnosis, and Treatment

As we age, there are some conditions that we are more predisposed to than others. Those over the age of 50 commonly have a condition known as hiatal hernia. A hernia occurs when any type of organ moves or slides beyond where it should be, usually pushing through a weak spot in a wall or cavity that would usually hold the organ in place. Read on to learn more about hiatal hernias, the causes, symptoms, and treatment, and how you can possibly prevent hiatal hernia as you age.

What Is a Hiatal Hernia?

Between everyone’s stomach and chest is their diaphragm, and there is a small part of the diaphragm known as the hiatus. The hiatus is a small opening in the diaphragm. A hiatal hernia occurs when the top part of the stomach pushes through into the hiatus. Usually, the esophagus would pass through the hiatus into the stomach; however, with a hiatal hernia, the top part of the stomach protrudes out when it should not. There are actually two separate types of hiatal hernias, which are slightly different from each other.

A sliding hiatal hernia is the most common type of hiatal hernia and is clearly described above. The sliding type of hiatal hernia occurs when the top part of the stomach pushes through the hiatus.

Paraesophageal hernia is not as common as a sliding hiatal hernia but can be more serious in some cases, warranting more scrutinized medical attention. Instead of the top part of the stomach pushing into the hiatus, a paraesophageal hernia occurs when the top part of the stomach pushes into the chest instead of the hiatus, next to the esophagus. This type of hernia also may have more noticeable or painful symptoms, such as chest pain.

What Causes Hiatal Hernia?

Like many other medical complications, especially those related to age, scientists, researchers, and doctors don’t have a strong grip on the exact cause of hiatal hernia. However, straining of any type is definitely thought to be linked to the development of a hernia. This includes straining you may not even think about while doing it, such as pushing too hard to have a successful bowel movement. Other types of “strain” can include:

  • vomiting
  • coughing
  • pregnancy
  • overexertion

Obesity is also strongly correlated with the development of both types of hiatal hernia. Those with a higher body mass index (BMI) seem to be more predisposed to hernia, especially after the age of 50.

Congenital anomalies of the diaphragm and sudden trauma to the esophagus or diaphragm (such as a motor vehicle accident) can also cause hiatal hernia; however, these are more rare. Pregnancy is thought to be a root cause of many hiatal hernias, as the growing fetus weakens organ walls.

What Are the Symptoms of a Hiatal Hernia?

Often, patients don’t realize they have any type of hiatal hernia because there are no symptoms that accompany the condition. This can be especially true if a hiatal hernia occurs during pregnancy as a patient may not feel symptoms from the hernia until she is much older. Quite regularly, doctors notice the presence of hiatal hernia while performing other tests for other conditions, such as an X-ray. Symptoms between sliding hernias and paraesophageal hernias are slightly different. The more common sliding hiatal hernia may cause symptoms such as:

  • feeling nauseous
  • heartburn
  • trouble swallowing
  • reflux
  • regurgitation
  • vomiting

A hiatal hernia may feel like a bad case of heartburn or acid reflux. However, if symptoms persist longer than what seems normal, it’s best to confer with a doctor.

As paraesophageal hernias are more serious, they have more serious symptoms and complications. Some symptoms of paraesophageal hernia include:

  • chest pain
  • abdominal bleeding
  • feeling full
  • anemia
  • blood loss
  • trouble eating (swallowing) and digesting food

Anyone experiencing chest pain or similar symptoms should see their doctor or seek emergency treatment as soon as possible.

When it comes to the prevention of hiatal hernia, some doctors and researchers disagree. Some clearly state there are no preventative tactics for a hernia because causes aren’t clear; however, other doctors believe you can help prevent a hernia by taking a few simple health-related steps.

Avoiding obesity is recommended in the prevention of hernia. This is accomplished by eating a healthy diet, exercising regularly, and keeping the BMI within the normal range.

Avoiding or reducing heartburn is also another step. Those who suffer from persistent acid reflux or gastroesophageal reflux disease (GERD) suffer more regularly from heartburn than those without the condition; however, both acid reflux and GERD are managed with medication or by avoidance of certain foods. Generally speaking, to avoid heartburn, you should limit the intake of tomatoes or acidic foods, spicy foods, alcohol, chocolate, and caffeine. Patients are also advised not to lie down immediately after eating, as this can cause indigestion, heartburn, and acid reflux.

Hiatal Hernia Exams and Tests

As previously mentioned, often doctors “catch” hiatal hernias when they’re looking for other conditions or problems. However, doctors can certainly check for hiatal hernia by using a few different types of means. One of the simplest ways is to have a chest X-ray, as doctors can see the hiatal hernia easily through the film. Patients may also be tested using an upper endoscopy, which looks at the lining of the stomach and esophagus, an upper GI or barium swallow series, which looks at the organs of the digestive system, and esophageal manometry, which checks the strength of the esophageal muscles. Many less serious hiatal hernias don’t require treatment, so if a hernia is suspected, the easiest way to check for it is by having an X-ray. Other tests may be used if other problems are suspected along with hernia, such as severe GERD caused by hiatal hernia or other troubles with the GI tract.

When to Seek Medical Care for a Hiatal Hernia

You should seek medical care for a hiatal hernia whenever symptoms are noticeable or painful. Symptoms of hernia can also mimic other GI disturbances, so if you’re experiencing frequent heartburn, pain, or are having trouble swallowing or eating, it’s best to consult a medical professional to be tested for hiatal hernia or other issues.

Less severe hernias, such as the more common sliding type, don’t really require any treatment. Your doctor may tell you much of the advice listed above, such as avoiding spicy food and not lying down after eating. However, there are other viable treatments for hernia, especially if the doctor thinks it is more serious. Doctors may advise over-the-counter treatments, such as antacids, for heartburn, or may prescribe something stronger, such as a proton pump inhibitor, to reduce stomach acid.

Very severe hiatal hernias can require surgery. In this instance, a patient will undergo general anesthesia and have laparoscopic surgery performed to pull the stomach back into place. Surgery is certainly the last option and is only discussed when medications and lifestyle changes have done nothing to reduce symptoms, heartburn, or pain. It is estimated that 90 percent of patients do see an improvement after having the surgery, which is known as laparoscopic Nissen fundoplication (LNF).

If you need more information about hiatal hernia, are experiencing symptoms, or need to see a physician, please book an appointment with Carolina Digestive Health Associates today. We offer specialized, individual care as well as eight separate locations for your convenience.

Question:

I have GERD and have been told that I may need surgery to repair a hiatal hernia. Can you please explain the surgery? Will my GERD be resolved? What are the potential risks related to the surgery?

Answer:

Since its introduction, laparoscopic surgery for gastroesophageal reflux disease (GERD) has become one of the more common operations performed in the United States.

Learn more about laparoscopic surgery

It is interesting that there is still not a consensus amongst physicians as to the proper role of this procedure in the management of GERD. Many physicians (especially surgeons) are very fond of this operation. However, many physicians (mostly non-surgeons) are very much opposed to it. Consequently, patients are often faced with information from different sources that appears to be completely contradictory.

The basic problem in patients with GERD is that acid from the stomach refluxes up into the esophagus (food pipe). The barrier that prevents this from happening is complex. However, there are only a couple of things that can go wrong here:

  1. The muscle at the bottom of the esophagus – the lower esophageal sphincter – may become weakened.
  2. One may have a hiatal hernia. (In health, the esophagus should be in the chest and the stomach should be in the abdomen. The diaphragm is a thin muscle that separates the chest from the abdomen. In people with a hiatal hernia, the stomach has moved up above the diaphragm and into the chest.)

When either of these problems happens, the barrier between the stomach and the esophagus is less competent and more likely to allow reflux of stomach acid into the esophagus. A hiatal hernia tends to make the anti-reflux barrier more open and weaker. Consequently, it allows acid reflux to occur more easily. The hiatal hernia itself usually does not cause symptoms unless it is very large.

Surgical therapy corrects these underlying problems. The surgeon can pull the stomach back into the abdomen, correcting the hiatal hernia.

Furthermore, whether or not a hiatal hernia is present, the surgeon can take the top part of the stomach (the fundus) and wrap it around the lower esophagus, much like a tailor can cuff a pair of pants (a procedure called fundoplication). This strengthens the lower esophageal sphincter muscle and helps prevent acid reflux from occurring.

The procedure can nearly always be done laparoscopically, using very small incisions. Typically, patients will spend the next one to two days in the hospital and 2–4 weeks at home recovering. Ideally, within a few weeks, patients will no longer have heartburn, and no longer need to take heartburn medication.

Most of the data on success rates comes from specialty centers where this type of surgery is performed every day and patient satisfaction is high. The same results are not seen in less experienced centers, where satisfaction rates are lower and complications ocurr more often.

The most common complications are difficulty swallowing, abdominal bloating, diarrhea, and nausea. Most patients can’t belch as well as they could before surgery, although the inability to belch is distinctly uncommon. About 25% of patients can’t vomit after surgery. A recently published study from the Veterans Administration showed that 62% of patients having surgery required medications for heartburn after 10–13 years.

There are some special situations that deserve mention. It appears that the ideal candidate for the operation is the patient with heartburn that responds nicely to medical therapy. Patients with atypical symptoms of GERD, such as laryngitis, chronic cough, or asthma don’t seem to do quite as well. Patients with a poor response to medical therapy may not do as well either. The main reason for this is that these patients may have problems besides GERD that are causing these symptoms that are unresponsive to treatment (refractory symptoms).

Some patients develop a stricture, which is a narrowing of the esophagus caused by severe acid reflux. The surgical results in these patients are not quite as good as in patients who don’t have a stricture. Having surgery for a stricture is still controversial, but it is my belief that most patients with this problem are better off not having surgery.

Another controversial area is Barrett’s esophagus. This is a situation where the lining of the esophagus changes to a potentially pre-malignant tissue. Some surgeons feel strongly that surgery will decrease the risk of developing cancer, and will so inform their patients. Unfortunately, there is no compelling scientific evidence that this is true. Most experts in this area believe that surgery should not be performed for the sole purpose of preventing esophageal cancer.

There are some people with a very large hiatal hernia, where one-half of the stomach or more is actually in the chest. The currently available medical therapy rarely works in these people and surgery is usually necessary.

Surgery for GERD should be considered in three circumstances:

  1. People who have side effects to medical therapy may require surgery. However, please keep in mind that there are now several proton pump inhibitors. It is uncommon to see a person who cannot tolerate any of them.
  2. People who are poorly responsive to medical therapy may benefit from surgery. However, as stated above, some refractory symptoms may be unrelated to GERD. The physician should be as certain as possible that the symptoms are indeed due to GERD.
  3. People who wish to be free of the need to take medications for their GERD may choose to have surgery.

Individuals must be aware that the overall satisfaction rate is around 95%, and the chance of being symptom-free is about 70%. I rarely have a patient ask me about what happens to patients who don’t do well; they seem to assume that they will be one of the 95% who have a good outcome. Many of these patients simply don’t respond and need to continue taking medication.

However, 1–2% of all surgical patients are worse after the procedure. It must be pointed out that the few patients who do poorly with this operation have a life-altering experience. They often have difficulty with swallowing, nausea, chest pain, or abdominal pain that is refractory to all medical and surgical therapies and occurs with every meal for the rest of their lives.

Experience has taught us several important lessons:

  1. There is no substitute for surgical experience. If you are considering surgery for the treatment of GERD, ask your doctor how many of these operations they have done. The best results can be expected from surgeons who have done 200–400 operations or more.
  2. The patients who do the best are those with simple heartburn that responds nicely to medical therapy. If your symptoms don’t respond to medical treatment, ask your doctor about how certain he or she is that the symptoms are related to GERD and not something else.
  3. Several diagnostic tests are imperative before surgery. Make sure to ask your doctor if all necessary testing is completed and that the results suggest that a good outcome will be obtained with a successful operation.

If these criteria are met, the chances are favorable for a good, long-term response to surgical therapy for GERD.

Adapted from IFFGD Publication: GERD, Hiatal Hernia, and Surgery by J. Patrick Waring, MD, Digestive Healthcare of Georgia, Atlanta, GA.

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