A hiatal hernia may also be called a hiatus hernia or diaphragmatic hernia. All three terms have essentially the same meaning.
What is a hiatal hernia?
In order to understand the condition, we must first look at some of the anatomy of the body. Between the abdomen and the chest there is a domed layer of muscle and tendons, the diaphragm; it might be thought of as both the ceiling of the abdominal cavity and the floor of the chest. The esophagus, the passage between the throat and the stomach, is in the chest, above the diaphragm, while the stomach lies below the diaphragm. There is a teardrop shaped opening – a “hiatus”- in the diaphragm, where the esophagus and the stomach join. At this junction there is a marvelously complex valve system that keeps stomach acid down where it belongs and out of the esophagus, which is normally either neutral or alkaline.
Now, a hernia is the protrusion of an organ through a wall of the cavity in which it is normally enclosed. In hiatus hernia it is the stomach that protrudes through the hiatus in the diaphragm into the chest cavity. By far, the greater number of hiatus hernias are of the so-called sliding type, in which the upper part of the stomach slides straight up through the diaphragmatic hiatus into the chest.
Is a hiatal hernia an unusual condition?
Far from it. It is found in people of all ages and both sexes. Generally speaking, it is a disorder of the middle years; some doctors feel that about half of the people over 40 years of age in this country probably have a hiatal hernia, especially if they are overweight or have borne a child. Yet it is sometimes, though not very often, found as a birth defect in newborn babies.
Why is a hiatal hernia so uncomfortable?
A hiatus hernia is painless; most people who have one don’t even know they have it. The symptoms of heartburn, indigestion and various frightening pains that bring people to the doctor’s office are due to esophagitis, or irritation of the esophagus, which is very often but by no means always associated with hiatus hernia.
What causes it?
The most frequent cause of hiatus hernia is an increase of pressure in the abdominal cavity, which is produced by coughing, vomiting, straining at stool or sudden physical exertion. Pregnancy, obesity or being overweight, or the collection of fluid in the abdomen are also among the causes, since they all increase the pressure in the abdomen and tend to exert pressure on the stomach.
Once a portion of the stomach protrudes through the diaphragm, the valves that protect the esophagus from stomach acid become ineffective and stomach acid can flow up into the esophagus. The acid is very irritating to the lining of the esophagus and produces the esophagitis.
Can these conditions be prevented?
Probably not. Some specialists in diseases of the digestive system are of the opinion that hiatal hernias arise because the muscles surrounding the hiatus in the diaphragm tend to slacken in later life or are that way from birth.
How severe a disorder is a hiatal hernia?
One must remember that most hiatal hernias do not cause symptoms and do not require treatment. However, if the hernia is complicated by esophagitis, with its heartburn and distress after meals, then treatment is very important. It is fortunate that the symptoms at this early stage of the disorder generally cause the patient to seek a doctor’s help, for the esophagitis, and to a certain extent the hernia, are relatively easy to control if caught in time. Untreated, both disorders can progress to disabling and in some instances, life-threatening conditions.
Esophagitis, for example, can develop into ulceration of the esophagus, with scarring and narrowing of the passage. In its severe form the patient may find it difficult or impossible to swallow solid food. Since the stomach acid wells up into the esophagus when the patient lies down, the acid may occasionally find its way into the lungs, where it can do extensive damage.
The protruding part of the stomach may be constricted by the hiatus, and blood may be trapped in the veins of the stomach lining. These congested tissues are very vulnerable to the development of sores or ulcers, which may lead to slow but steady loss of blood, and then to anemia. Occasionally, the bleeding may be rapid and massive with vomiting of blood or passage of blood in the stools.
One of the peculiar characteristics of a hiatal hernia is its ability to mimic other conditions, such as various types of heart disease, ulcers or disorders of the gallbladder or pancreas. Modern methods of diagnosis have made these distressing errors rare. Of course, just because an individual has a hiatal hernia doesn’t mean that he or she can’t have gallstones, ulcers or heart disease or other disorders at the same time. In fact, hiatal hernias are frequently found along with gallbladder disease and diverticulosis, a disorder of the large intestine.
Is this purely a physical complaint or can it be psychosomatic?
Most evidence points to hiatal hernia and its associated esophagitis as being brought about by physical pressure on the stomach. However, some people find it difficult to swallow when they are tense or upset, and there is reason to believe that emotional tension may increase the secretion of stomach acid. So, while the disorder is primarily physical, its distress may be aggravated by emotional factors.
What can the doctor do for me?
The first job your doctor will tackle will be to get you some relief from the symptoms of esophagitis – the heartburn and indigestion – by prescribing an antacid. This will neutralize the stomach acid and probably reduce the inflammation of the esophagus. Some common sense advice will follow: don’t wear tight clothes, don’t do anything that involves bending forward when your stomach is full, such as weeding the garden or scrubbing the floor, because these all increase the pressure in the abdomen. If you are bothered by heartburn when you go to sleep, blocks to raise the head of the bed 4 inches will help. You will be cautioned against overeating. Several little meals will probably cause you less distress than one big meal. Smoking and smokeless tobacco aggravate symptoms of esophagitis and should be stopped. Other medications to reduce acid secretion and prevent acid reflux into the esophagus may be necessary.
Can diet help?
By the time you came to seek the doctor’s help, you probably had a fair indication of which foods and drinks you could take and which caused distress. Most people find that highly spiced dishes irritate the esophagus, while bland foods are fairly well tolerated. In fact, if your esophagitis is severe, your doctor may put you on a very bland diet for the first few days, then progressing to a more normal diet over a few weeks. The feedings will be small and frequent, and the last meal at night will be not less than two hours before you go to bed.
Alcohol in any form and carbonated beverages will probably give you trouble and should be avoided while the esophagus is inflamed. For some reason that is not completely understood, orange juice, danish pastry or sweet rolls and cakes with icing are also troublemakers and should be avoided. Coffee intake generally should be reduced.
Of course, if you are overweight and have a hiatus hernia, there is another diet in your future – a reducing diet.
Suppose none of these measures work – what then?
Most cases of hiatus hernia with esophagitis respond to antacids, bland diet, weight reduction, medications and common sense. However, if the heartburn, pain in the chest and other symptoms persist, there are several operations available to correct hiatus hernia. An operation is to be considered if there is any danger of lung damage from the stomach acid. The purpose of the operation is to restore the stomach to its proper position and strengthen the area around the hiatus. About 80% of the time these operations are successful in getting the valves at the bottom of the esophagus to function normally again.