What Is A Hiatal Hernia?

Are you suffering from acid reflux, the feeling of stomach fullness even after eating very little food, a burning sensation in your chest, and pain or difficulty swallowing? Then you might have a hiatal hernia. 

A hiatal hernia happens when a portion of your stomach pushes through your diaphragm (the muscular sheet separating your chest and your abdomen) and rises up. Your oesophagus, the tube that carries food from your mouth to your stomach, generally passes through a tiny gap in your diaphragm called the hiatus. A hiatal hernia may develop if the stomach pushes upwards through this gap.

If you're over 50, it’s not very uncommon. It often doesn't need to be treated if it's not bothering you. A hiatus hernia can exist without the sufferer being aware of it or experiencing any symptoms.

Overview

The term "hiatal" refers to the hiatus, which is anatomically defined as a gap or opening. It especially refers to the diaphragmatic hiatus, where the oesophagus crosses to join the stomach, in the context of a hiatal hernia. The Latin word "hernia," which means "rupture" or "protrusion".  A tissue or organ protruding through an unusual opening is referred to as a hernia in medical language. When a portion of the upper stomach bulges into the chest, it is known as a hiatal hernia. Larger stomach parts or possibly other bowel segments that are forced up into the chest are referred to as para-oesophageal hernias.

The stomach usually lies below the diaphragm, however, in cases of hiatal and para-oesophageal hernias, the stomach can be located above the diaphragm.¹ Due to the hiatal hernia's tendency to constrict the stomach due to the diaphragmatic hole, acid along with other contents are retained. These chemicals and acids can readily reflux or regurgitate into the oesophagus. 

Hiatal hernia is grouped into four types:

• Type 1- It is also referred to as a sliding hernia, which accounts for more than 95% of hiatal hernias. Here, the gastroesophageal junction (GEJ) (the junction between the oesophagus and the stomach itself) slides and moves upwards towards the hiatus.²
• Type 2- It is also called a para-oesophageal hiatal hernia. This happens when a portion of the stomach moves parallel to the oesophagus into the chest cavity.²
• Type 3- It is a combination of both sliding hernia and para-oesophageal hernia where a part of the stomach has moved into the mediastinum along with the gastroesophageal junction (GEJ).²
• Type 4- Here, the stomach herniates into the chest, along with another organ such as the colon, small intestine, or spleen.²

Causes of hiatal hernia

The exact cause of a hiatal hernia is not always known. Although, some studies report that the phrenoesophageal ligament, an elastic ligament which anchors the oesophagus to the diaphragm, may be implicated The oesophagus shortens above the diaphragm with each swallow, stressing this elastic ligament. The distal end of the oesophagus is then pulled back to its usual place at the level of the diaphragm by the elastic rebound of the ligament following the completion of the swallow. With repeated swallowing or other stressors (such as vomiting or gastroesophageal reflux), the elastic ligament that holds the distal oesophagus in place is thought to deteriorate, leading to a sliding hiatal hernia.

It is believed that the ligaments holding the stomach in place generally have an abnormal laxity in the case of a para-oesophageal hiatal hernia, although it is unclear whether this flexibility is the cause or an effect of the hernia. Hiatal hernias can either be congenital or result after gastric or esophageal surgery.

Signs and symptoms of hiatal hernia

A hiatus hernia may not exhibit any symptoms in some cases, but in other cases, it may present with:

• Gastroesophageal reflux disease (GORD)
• Pain and difficulty in swallowing
• Hoarseness of voice
• Chest pain
• Abdominal pain
• Regurgitation
• Belching
• Fullness of stomach
• Blood in stool
• Shortness of breath.

Many paraesophageal hernia patients either show no symptoms or have sporadic, ill-defined symptoms. These may include:

• Discomfort in the upper abdomen or lower chest
• Sensation of fullness after eating very little
• Nausea
• Change in bowel habits

The stomach may twist and cause blockage if para-oesophageal hernias become large. Cameron lesions, which are stomach ulcers that can develop in any kind of hiatal hernia and lead to anaemia or gastrointestinal bleeding, are also possible.

Management and treatment for hiatal hernia

The kind of hiatal hernia and the severity of the symptoms determine how it should be managed.

The primary objective of treatment for a sliding hiatus hernia is often to reduce GORD symptoms like heartburn. Since GORD is the most prominent symptom in patients with hiatal hernia, lifestyle changes (such as weight loss and elevating the head of the bed) should be encouraged. Symptomatic patients should then be prescribed antacids (to neutralise stomach acid), prokinetics (to increase gastrointestinal motility), H2-receptor antagonists (reduces the amount of acid produced by the stomach), and proton pump inhibitors (also reduces the amount of acid produced by the stomach). Acid suppression via proton pump inhibitors is the mainstay of therapy. Surgery is typically only suggested as a last resort when long-term medication is no longer effective or if alternative treatments have failed.

On the contrary, the paraesophageal hiatal hernias require surgical correction regardless of the absence of symptoms, because of the possibility of developing consequences such as bleeding, blockage, and perforation.³ In order to treat a hiatal hernia, the intra-abdominal oesophagus must be repaired, and the diaphragmatic hiatus must be rebuilt. Surgical care should also include strengthening the lower oesophageal sphincter with an antireflux surgery. Although a number of endoscopic management approaches for GORD have been developed, it is doubtful that these treatments will be successful in treating hiatal hernia as the underlying anatomic problem cannot be rectified.³

Diagnosis

Diagnosis will be made using a combination of a description of your symptoms, as well as results of a variety of clinical tests. These may include:

• Barium swallow x-ray - this provides crucial information on the gastroesophageal junction's location and the size of the herniated stomach. The majority of research agree that barium swallowing is still crucial for identifying hiatal hernias.⁴
• Esophagogastroduodenoscopy (EGD) - this gives a real-time study of the oesophagus, stomach, and duodenal mucosa and can identify lesions that could be cancerous as well as erosive esophagitis, Barrett's oesophagus, Cameron's ulcer, and other conditions.⁴
• Manometry - this gives a lot of useful information about esophageal motility. It is very important to do esophageal manometry before having surgery, since it can rule out achalasia or other motility abnormalities.⁴
•  pH testing - because tpH level is correlated with the signs and symptoms of acid reflux, it has been effective in giving a quantitative study of reflux episodes.⁴
• Computed tomography (CT) - CT scans continue to be significant in providing additional information on the type and location of hiatal hernia.⁴

Risk factors

Although anybody can develop a hiatus hernia, those who are older than 50, overweight, and/or pregnant have a higher risk. Hiatus hernias are thought to affect one-third of adults over the age of 50.

FAQs

How can I prevent hiatal hernia?

Some specific lifestyle alterations can be made to lower the risk, or lessen the symptoms of a hiatal hernia, even though it may not always be able to prevent it. Some of those modifications are

• Maintaining a healthy body weight
• Having smaller portions of food
• Practising breathing exercise, as this helps to strengthen the abdominal muscles
• Avoiding carbonated drinks
• Managing acid reflux²

How common are hiatal hernia?

Hiatal hernias are more common as people age, therefore they are mostly found in the elderly. However, there is an uncommon type of hiatus hernia that develops in new-borns and is brought on by a diaphragmatic or stomach congenital abnormality. An estimated 55% to 60% of those over 50 have a hiatal hernia.

Only 9% of people have symptoms, and this varies depending on the shape and functionality of the lower oesophageal sphincter. Type I sliding hiatal hernias constitute the vast majority of these hernias. Hiatal hernias of Type II, or para-oesophageal hernias, account for just 5% of cases.² 

Additionally, there is a rise in prevalence in women, which may be related to higher intra abdominal pressure during pregnancy. The two regions of the world where hiatal hernias are most common, are Western Europe and North America.⁴

When should I see a doctor?

You should immediately seek medical advice if you are having unexplained weight loss, difficulty swallowing, frequently feeling nauseous, blood in your vomit, and extreme pain in your upper abdomen.

Summary

A hiatal hernia is a condition when a portion of the stomach pushes through the diaphragm's hiatus (opening) and into the chest. Although the exact cause of hiatal hernias is not known, several conditions might facilitate their growth, including: age (hiatal hernias are more prevalent in older persons), obesity, pregnancy, constant pressure on the abdomen (from heavy lifting or straining during bowel movements), and weakened diaphragm muscles.

Hiatal hernias are often diagnosed by a review of medical history, physical examination, and imaging procedures like X-rays, barium swallows, or endoscopies. Options for treating a hiatal hernia depend on how severe the symptoms are. Modifying your lifestyle and taking drugs to treat symptoms like heartburn might help manage mild instances. Surgery may be suggested to correct the hernia in more severe circumstances or if problems develop.