Hiatus hernias

At the outset, we must establish that HIATUS hernias are different to the ABDOMINAL WALL hernias we cover elsewhere on this hernia.org website.

Unlike an abdominal (or groin) hernia, a hiatus hernia occurs in the chest area and affects the digestive system.

Where the oesophagus (the “gullet” – connecting the mouth with the stomach) goes down, it passes the diaphragm through a gap called the hiatus.

Immediately below that, it goes into the stomach which sits just below the diaphragm.

droppedImageThis hiatus causes a narrowing of the opening into the stomach and this helps prevent stomach contents from going the wrong way, i.e. upwards, which is called reflux.

If the area of the hiatus is weak, the function of clamping down on the entry to the stomach is weakened, the result being the reflux of acidic digestive juices up into the oesophagus, which is not protected against the action of these acids. The outcome of this is often a quite painful burning sensation. Should reflux occur in one’s sleep, there is a real risk of aspirating the acid mixture (‘breathing’ it in to the lungs) which can have a devastating outcome – we will come back to that below. Other symptoms patients suffer include severe chest pain which may extend to just below the shoulder blades.

The  page following this one describes the serious condition called Barrett’s Oesophagus – an important possibility following long-term reflux.

At its worst, hiatus hernia pain can mimic that of a heart attack. It is not uncommon for patients to arrive at a hospital Emergency Department (A&E) with a suspected heart attack and only after professional tests is the the cause revealed. To describe this as ‘distressing’ is an understatement.

Unlike an abdominal hernia, there are no tell-tale visible symptoms of hiatus hernia, as the whole event occurs inside the chest. The diagnosis is established by a specialist; the combination of symptoms must be confirmed by X-ray and an endoscopy (a view using a lighted tube).

Reflux and Coughing

As mentioned above, another troubling effect of reflux is that the acidic stomach contents can rise up the oesophagus as far as the throat. The throat area, of course is where the trachea (‘windpipe’) and the oesophagus (‘gullet’) come together. This has two common consequences. One is that awful taste of vomit (which is, of course, what it is). However, a more serious consequence that can happen is aspiration (‘breathing in’) the acidic liquid of the reflux. The body is extremely sensitive to anything other than a gas (like air) entering the lungs so the acid triggers an instant reflex reaction. At its mildest that would be a coughing fit to clear the airway. At its worst, it can actually choke the sufferer, with the windpipe going into spasm and choking off all the airflow into the lungs. Another manifestation of this problem is a long-term cough.

What can be done to avoid a hiatus hernia?

Whilst there is nothing that one can do to prevent the occurrence of a hiatus hernia, there are three ways of dealing with the symptoms.

1 – Lifestyle

There are certain things one can do, some obvious and some less so. If one can identify, for example, that certain foods aggravate the condition whilst others do not, then simple avoidance of those foods is an easy way of avoiding discomfort.

Further, it is clear that to eat a heavy meal and promptly go and bend over digging the garden is not sensible if it is known to cause problems. Lifting or moving heavy objects has a similar effect. Again, this is an example where one can spare one’s self the symptoms by simple adjustment to the timing and choices of these activities. However, for some patients, even drinking a glass of water before lying down can cause hours of discomfort.

The answer here may be to avoid eating or drinking for an appropriate amount of time before lying down. Eating ‘little and often’ is also helpful.

There are also certain adjustments one can make to one’s bed in order to change the angle. This can also assist in reducing the occurrences of reflux. One common remedy has been to place two bricks under the bed’s feet at the head end so the sufferer does not lie completely flat, but with just that slight slope so gravity helps keep things ‘down’. As with several other conditions, the problem is actually often quite ‘mechanical’ and is remedied by simple mechanical means.

The advantage of the lifestyle approach is that you might avoid medical or surgical intervention altogether and be able to live with the condition without suffering the symptoms. The disadvantages are that it may not be possible to find a lifestyle that deals with the symptoms and the inconvenience caused may be intolerable.

2 – Medicine

There are several different medicines available to deal with the symptoms of hiatus hernia. They work in different ways, but are normally of an antacid type, and some work better on certain patients and others better on other patients. You should ask your doctor to suggest one or other type and, if that does not help, he may suggest a different one.

An important note here about medicines. Chronic (long-term) indigestion should ALWAYS be referred to your doctor. We do not recommend you choose your own medication, even over-the-counter. Only your doctor will be able to properly assess what you need.

The advantage of the medicinal approach is that, in certain cases, this allows the patient to avoid all symptoms without too much inconvenience. The disadvantage is that it may not be desirable to take medicine for the rest of one’s life.

3 – Surgery

The surgery for hiatus hernia should not be confused with the techniques described for abdominal wall hernias. The surgical procedures are different.

We would say that no decision should be taken to proceed to surgery for hiatus hernia lightly. A proper specialist diagnosis is essential.

For many cases of hiatus hernia, it is perfectly possible to end the problem once and for all by a procedure which makes a stronger ‘valve’ function. This is accomplished by tightening the hiatus area in order to keep the stomach in its correct place below the diaphragm, and which reinstates the correct opening into the stomach,  preventing the reflux and other symptoms. At The British Hernia Centre, we effect the procedure through tiny incisions using a ‘keyhole’ technique.

The patient is admitted to Hospital for usually no more than one night and there follows a recuperation period of about a week. After this time, most patients are able to get back to virtually their normal routine without any of the symptoms of the hiatus hernia.

Despite the very high success rate of this operation, we follow the following important steps before planning the procedure:

  • Confirming the correct diagnosis
  • Ensuring that the patient has tried the alternative methods of lifestyle and medicine

General tips

There are several foods and other matters that are commonly associated with aggravating the symptoms. Before considering medicines or surgery, it is often worthwhile making changes to avoid such things as:

  • Hot (too hot) foods and drinks
  • Spicy foods
  • Acidic and acidifying foods
  • Fizzy drinks & fruit juice
  • Foods which are difficult to digest
  • Smoking
  • Alcohol
  • Being overweight
  • ANYTHING that gives you heartburn / indigestion

We are asked:

Q: “Is antacid medication likely to work in the long term because nothing I take makes any difference to the discomfort and pain. I wake up with acid in my throat which is horrible and I take medication, but it does not go away. Do antacids really make any difference once a hiatus hernia has developed?”

A: Antacids are used to treat symptoms, not the cause. By the time you feel the need to take them, damage has been done by the very act of burning you. At worst, acid reflux, especially in your sleep can have the worst imaginable outcome. Antacids are wonderful, but in most cases, are NOT the long-term answer.

What to do next

We advise people who contact us from all over the world that the best course of action is to have the endoscopy and x-ray tests performed locally and then contact us to advise the most appropriate treatment, including surgery (if that is what is required). Your own family physician should be able to arrange the necessary ‘basic’ tests.

If those tests indicate that a hiatus hernia exists, then contact us with those results and we will be happy to advise on how best to proceed.

To see a few Frequently Asked Questions on Hiatus Hernia click here

For a completely free, personal opinion on your own hiatus hernia, give us some key details HERE. We will consider what you tell us and get back to you with our opinion. There is no obligation whatsoever and of course, it is confidential.

Next:  Hiatus Hernias and BARRETT’S OESOPHAGUS