Hiatal Hernia

Oral and Gastrointestinal

Having a hiatal hernia can be a painful condition. They occur deep inside the body and cannot be seen from the outside like other hernias. A hiatal hernia happens when the upper stomach pushes up into your chest area through an esophageal hiatus. This is an opening in the diaphragm that is normally just for the esophagus to pass through. This area of the diaphragm can become weak and stretch to allow the stomach to pass through. Women are affected with hiatal hernias more than men and often as a result of pregnancy. Even though they can be painful, 50% of people affected with this condition have no symptoms at all. In general, hiatal hernias occur in around 60% of all adults by 60 years of age. Most hiatal hernias are observed without intervention with only severe cases requiring surgery.

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Symptoms

If you have a very small hiatal hernia, you may not have any symptoms at all. If they are big enough to cause symptoms, you may feel:

  • Frequent heartburn
  • Regurgitation
  • Acid reflux
  • Upper abdominal pain
  • Trouble swallowing
  • Excessive belching
  • Extreme fullness after eating
  • Blood in vomit or stools

More severe symptoms of hiatal hernias (paraesophageal or fixed)

  • Chest pain
  • Abdominal pain
  • Abdominal bleeding
  • Blood loss or anemia

Any of the above symptoms should be evaluated by a doctor, especially if you are vomiting blood which could be a sign of a bleeding ulcer or something more serious. In cases of extreme abdominal pain, a person with a hiatal hernia may have stomach or abdominal organs that are turned and twisted. This also is a medical emergency.

Types

There are two different types:

Sliding hiatal hernia. Most common type of hiatal hernia. This happens when the stomach slides up when there is more pressure inside the abdomen. It slides back down when the pressure is relieved.

Paraesophageal or fixed hiatal hernia. Less common and usually more serious. The hernia does not move, and the upper part of the stomach is “fixed” in its position through the esophageal hiatus.

Risk Factors

  • Genetics
  • Age over 50
  • Obesity
  • Being pregnant
  • Smoking

Diagnosis

If you have symptoms of a hiatal hernia, make an appointment with your doctor. Make sure you make a list of your symptoms and how long you have had them. Let your doctor know any medications you are taking and any medical history. After a physical examination, the doctor may order one or more of the following tests:

Lab tests. You may need a complete blood count (CBC) to make sure you are not anemic and a test for the bacteria that causes ulcers, H. pylori. The doctor may also check your liver functions, which can cause upper abdominal pain.

Barium swallow study. For this test, you will need to drink a barium liquid that will allow the doctor to see your stomach on an x-ray. They can see any problems going on with your upper intestines, stomach, and esophagus.

Endoscopy exam. This exam uses a lighted tube and camera to look at the stomach and esophagus. The doctor will check for signs of inflammation, ulcers, and signs of bleeding.

Manometry exam. The doctor will place a small tube down the back of your throat to check for pressures in the esophagus.

Grading according to type

During diagnosis, your doctor will “grade” the hernia to help determine the best treatment for you. Here are the different types and grades:

  1. This is known as a “sliding hernia” and moves up and down with pressure changes in the abdomen. This is one of the more common hiatal hernias.
  2. This type is a “rolling hernia” or also known as para esophageal. Most of the stomach remains below the diaphragm and a small portion herniates upward. This type is not as common.
  3.  This is the combined or mixed hernia. The majority of the stomach pushes up through the opening and can sometimes even twist. These are less common than type I and II.
  4. In this type, not only the stomach herniates upward but other organs like; intestines, pancreas, and spleen. This is a rare form of hiatal hernia.

Most hiatal hernias are either Type I or Type II and can be easily managed. Type III and IV often require surgery to reduce the hernia and repair the opening.

Treatments

Once the doctor has given your hernia a type and grade, a treatment plan will be put in place. This may include one or more of the following:

Type I and type II showing no symptoms

  • Medications (i.e., acid reducers, motility drugs)
  • Dietary changes
  • Smaller more frequent meals
  • Staying upright after eating
  • Weight loss
  • Smoking cessation
  • Elevating the head of the bed

Type I and type II with symptoms

  • Fundoplication surgery – This is not a hernia repair but takes a small amount of the upper stomach and wrapping it around the lower esophagus to prevent reflux of stomach acid and contents. This effectively treats any accompanying GERD with the hernia to improve comfort.

Type III and type IV

  • Laparoscopic surgeryThis is the safest type of surgery to repair a hiatal hernia. This does not require large open incisions, only small ones to place the scope in and do needed repairs. This type is effective for even severe hernias.

Alternative Treatments and Home Remedies

Alternative medicine may be helpful for symptoms of hiatal hernia. Always ask your doctor before using herbal remedies because there may be drug interactions. The following herbs may help relieve reflux and pain:

Apple cider vinegar. Many people find it amazing that something acidic can lower the acid levels in the stomach. This is because the acetic acid in apple cider vinegar has a lower pH level which lowers the stronger hydrochloric acid in the stomach. Take 2 or 3 teaspoons in 8 ounces of water with meals.

Probiotics. Increasing the “good” bacteria in the digestive system can help digest food quicker and more efficiently. They can also help balance the pH levels in the digestive tract.

Slippery elm. This herb can leave a protective coating on the lining of the esophagus and stomach. This can lower inflammation levels. It can also increase the production of mucus in the stomach that reduces the acid levels.

Chamomile. Chamomile is a natural anti-inflammatory and can soothe stomach issues. Try drinking chamomile tea up to four times daily.

Gentian tea. Drink ½ hour before eating. Gentian tea can ward off heartburn caused by eating. Use 1 teaspoon in one cup of water and simmer for around 30 minutes.

Calendula tea. Can help reduce inflammation in the esophagus.

Lifestyle Changes

Lifestyle changes can help reduce discomfort and symptoms. Try the following:

  • Quit smoking and avoid secondhand smoke
  • Eat smaller more frequent meals
  • Avoid greasy and spicy foods
  • Avoid caffeine and alcohol
  • Try to lose weight if overweight
  • Use a pillow to elevate the head of your bed when sleeping
  • Do not lie down after meals. Sit upright for at least 30 minutes to an hour
  • Ask your doctor about exercises that help improve stomach muscle tone

References

Cedars Sinai. (2021). Hiatal hernia. Retrieved from Cedars Sinai: https://www.cedars-sinai.org/health-library/diseases-and-conditions/h/hiatal-hernia.html

Johns Hopkins Medicine Staff. (2021). Hiatal hernia. Retrieved from Johns Hopkins Medicine: https://www.hopkinsmedicine.org/health/conditions-and-diseases/hernias/hiatal-hernia

Kohn, G. P., et. al. (2013, April). Guidelines for the management of hiatal hernia. Retrieved from the Society of American Gastrointestinal and Endoscopic Surgeons: https://www.sages.org/publications/guidelines/guidelines-for-the-management-of-hiatal-hernia/

Levy, J. (2017, March 11). Hiatal hernia symptoms + 5 natural remedies. Retrieved from Dr. Axe: https://draxe.com/health/hiatal-hernia/#5_Natural_Remedies_for_a_Hiatal_Hernia

Sfara, A. & Dumitraşcu. (2019, September). The management of hiatal hernia: an update on diagnosis and treatment. Medicine and Pharmacy Reports, 92(4). Retrieved from ResearchGate: https://www.researchgate.net/publication/335781621_The_management_of_hiatal_hernia_an_update_on_diagnosis_and_treatment

Siegal, S. R., Dolan, J. P. & Hunter, John G. (2017, December). Modern diagnosis and treatment of hiatal hernias. Langenbeck’s Archives of Surgery, 402(8), 1141-1151. Retrieved from PubMed: https://pubmed.ncbi.nlm.nih.gov/28828685/

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