A hiatal hernia is present when the stomach pushes into the chest cavity from the abdominal compartment, through a natural opening in the diaphragm. The diaphragm is a thin muscle that moves each time we breathe. Hiatal hernias range in size from a tiny one of no importance to a large one where the entire stomach and even other organs can dangerously shift into the chest.
What are the symptoms of a hiatal hernia?
Because a hiatal hernia occurs internally, there is no visible bulge on the body surface. Many Hiatal hernias, even large ones, may have few symptoms; but even large hernias without severe symptoms may be best repaired before they cause trouble. The most common symptoms are gastroesophageal reflux or GERD. The diaphragm helps keep acid and food in the stomach, so when it becomes damaged with a hiatal hernia, reflux disease is more common. Small Hiatal hernias are very common, and most of them don’t require surgery. As reflux disease worsens, or the hernia enlarges, repair may be recommended. This may prevent worse damage from reflux or a hernia that gets trapped, or incarcerated, in the chest. The larger a hernia, the more likely it can twist and cause problems. Common symptoms of hiatal hernia are:
- Difficulty swallowing
- Difficulty belching or vomiting
- Chest pain, especially with or after meals
- Shortness of breath, or inability to take a deep breath
- Pain under the ribs
- Gastrointestinal bleeding and iron-deficiency anemia
What causes a hiatal hernia?
We can’t always identify a single cause, but like other abdominal hernias, high pressure in the abdomen increases the risk. Obesity, COPD, chronic cough, heavy lifting, and trauma may contribute. Tissues weaken with advancing age, and women appear more susceptible to large hiatal hernias.
How is a hiatal hernia diagnosed?
Many large hernias are discovered accidentally on an x-ray intended to look at something else. These incidentally discovered hernias tend to be the largest ones, and should be evaluated further using more specific tests. In particular, CT scans or even a simple chest x-ray may show a large hernia because a stomach gas bubble shows up behind the heart—where it doesn’t belong!
More specific tests for hiatal hernia include:
- Upper GI or barium swallow: The patient drinks barium x-ray contrast while pictures of the swallowing function are taken. Hiatal hernias are usually easily seen, as well as narrowing, tumors, and some swallowing disorders. It is an easy test that gives a lot of information!
- Endoscopy: The patient is sedated and a flexible scope is passed into the esophagus, stomach, and duodenum. This is the best test to start the evaluation if there is GERD (reflux disease), there is difficulty swallowing, or surgery might be considered. It allows for stretching the esophagus and taking important biopsies, as well as testing abnormal acid levels present with GERD. While more involved than the Xrays, endoscopy is extremely safe, provides a tremendous amount of information, and there is little preparation or recovery needed.
How is a hiatal hernia repaired?
The majority of hiatal hernias are not large enough to directly cause problems other than reflux, so they may be observed if reflux control is good without surgery. As the hernia enlarges, it may cause chronic bleeding due to ulcers in the hernia or may become distorted and risk being trapped, or incarcerated. Since incarceration can lead to gangrene of the stomach, larger hernias are usually repaired electively. So, the treatment recommended depends on an assessment of your risk based on a combination of symptoms, complications, and the size and shape of your hiatal hernia.
- Lifestyle changes: Maintain a healthy weight, stop smoking, eat smaller portions and avoid foods that cause reflux symptoms—acidic foods like tomato sauce, carbonated beverages, caffeine, chocolate, and alcohol. Elevation of the head of the bed may reduce nighttime reflux symptoms.
- Medications: Over-the-counter medications like antacid tablets and liquids can help brief heartburn, and acid-reducing pills are available OTC and by prescription. These are excellent for relieving heartburn in most patients, but regurgitation will continue unchanged. Most patients will notice it less.
- Surgery: Some mechanical complications such as twisting or obstruction of the stomach, unusual chest pains, or bleeding from the lining of the stomach will only be remedied by surgery to correct the hernia. Laparoscopic (minimally invasive) surgery assures most patients spend only a night in the hospital after surgery and their diet returns to normal quickly. Surgery repairs not only the hernia but controls reflux disease as well and lets patients stop reflux medicines. We have done thousands of surgeries to repair Hiatal hernias and reflux and have excellent results!
Do I need treatment?
If you believe you’ve been diagnosed with a significant hiatal hernia, have reflux disease or simply aren’t sure whether you are at risk, we can help you decide the best evaluation to answer your questions and determine what treatment is appropriate based on your situation. We have extensive experience. The good news is that patients treated at a high-volume center like Northeast Georgia Health System have better outcomes.
About Dr. Casey Graybeal
Casey J. Graybeal, MD, FACS of the Heartburn and Swallowing Center of NGPG Surgical Associates has over 32 years of experience in general surgery and specializes in foregut surgery for reflux, hiatal hernia, and swallowing problems. His philosophy of patient care revolves around the importance of patients well educated about their disease who participate in developing an appropriate and tailored treatment plan individualized for them.