In my last article we discussed about hernia especially about groin hernias. This time we will highlight a few important facts about hiatus hernia.
What is a hiatus hernia?
A hiatus hernia occurs when a part of the stomach pushes up into the lower chest through a defect in the diaphragm. The diaphragm is a large flat muscle that separates the lungs from the abdomen. It helps us to breathe. The gut or gastrointestinal tract, is the tube that starts at the mouth, and ends at the anus. The upper gut includes the oesophagus (gullet), stomach, and duodenum. Food passes down the oesophagus into the stomach. The oesophagus comes through a hole (hiatus) in the diaphragm just before it joins to the stomach. After being mixed in the stomach, food passes into the duodenum (the first part of the small intestine) to be digested. At the junction of the stomach and the oesophagus there is a thickened area of muscle which is called a sphincter. The muscle fibres in the diaphragm around the lower oesophagus help the sphincter to keep the oesophagus closed to prevent the reflux of acid and food. When food comes down the oesophagus into the stomach, the sphincter relaxes. However, it closes at other times to stop food and acid in the stomach refluxing back into the oesophagus.
Types of hiatus hernia
* Sliding hiatus hernia is the most common type. In this situation the sphincter at the bottom of the oesophagus and the top of the stomach protrudes through the hole (hiatus) in the diaphragm. The hernia may slide up and down, in and out of the lower chest. It is often quite small.
* Rolling hiatus hernia is less common. In this situation, part of the stomach protrudes up through the hole in the diaphragm next to the oesophagus.
What causes hiatus hernia?
The exact number of people with a hiatus hernia is not known. Many people with a hiatus hernia do not have symptoms. Some studies suggest that up to a third of people develop a hiatus hernia sometime in their life, most commonly in middle age. Many are small.
The cause of hiatus hernia is not clear. It is thought that most develop in people over the age of 50. It may be that the diaphragm weakens with age and allows part of the stomach to protrude through the hole in the diaphragm. The exact cause of hiatus hernia is uncertain, but it is more common in people who are
* over 50 years;
* smokers;
* those who are overweight or obese;
* women who are pregnant.
It is thought that physical efforts, eg excessive coughing, vomiting, straining or sudden physical exertion can be a contributing factor in hiatus hernia.
What are the symptoms?
Many people with a hiatus hernia have no symptoms.
Acid reflux symptoms
The hernia itself does not cause symptoms. However, if you have a hiatus hernia, the factors that normally prevent stomach acid from refluxing into the oesophagus may not work so well. The refluxed acid can cause inflammation of the lower part of the oesophagus which can cause one or more of the following symptoms:
* Heartburn is the main symptom. This is a burning feeling which rises from the upper abdomen or lower chest up towards the neck. (It is confusing as it has nothing to do with the heart!)
* Other common symptoms include pain in the upper abdomen and chest, feeling sick, an acid taste in the mouth, bloating, belching, and a burning pain when you swallow hot drinks.
* Some uncommon symptoms may occur, for example,
– a persistent cough, particularly at night, sometimes occurs.
– Other mouth and throat symptoms sometimes occur such as gum problems, bad breath, sore throat, hoarseness, and a feeling of a lump in the throat.
– Severe chest pain develops in some cases (and may be mistaken for a heart attack).
How is hiatus hernia diagnosed?
A hiatus hernia may be diagnosed if you have tests for symptoms of reflux. Endoscopy is the common test. This is where a thin, flexible telescope is passed down the oesophagus into the stomach. This allows the doctor to look inside the stomach and oesophagus. A hiatus hernia may be seen. A special X-ray test called a barium swallow is another more accurate way to confirm the presence of a hiatus hernia.
Treatment
* If you have no symptoms, you do not need any treatment. The hiatus hernia itself causes no harm.
* If you have reflux symptoms, then treatment is the same as for any other cause of reflux symptoms. Treatment includes lifestyle factors such as losing weight if you are overweight, antacids and acid-suppressing drugs.
* Rarely, a hiatus hernia causes severe symptoms of reflux which are not helped so well with medication. Therefore, an operation is occasionally advised. During this operation the stomach is put back into the correct position, and the weakened diaphragm around the lower oesophagus is tightened.
What are the possible complications of a hiatus hernia?
Possible complications may occur if you have long-term reflux of acid into the esophagus which occurs in some cases. These include
* Stricture – If you have severe and long-standing inflammation it can cause scarring and narrowing (a stricture) of the lower oesophagus. This is uncommon.
* Barrett’s oesophagus – In this condition the cells that line the lower oesophagus change. The changed cells are more prone than usual to become cancerous. (About 1 or 2 people in 100 with Barrett’s oesophagus develop cancer of the oesophagus).
* Cancer – Your risk of developing cancer of the oesophagus is slightly increased compared to the normal risk if you have long-term acid reflux. This small increased risk is slightly higher still in people with reflux plus a hiatus hernia. This is because reflux problems, on average, tend to be more severe in people with a hiatus hernia compared to those without.
It has to be stressed that most people with reflux or hiatus hernia do not develop any of these complications.
Prevention
Symptoms can be prevented or reduced by
* eating frequent small meals;
* avoiding foods that are hot, spicy, acidic or difficult to digest;
* in cases where a patient is overweight, losing weight will help minimize the symptoms;
* avoiding tight-fitting clothes;
* elavating the head of the bed by 4-6 inches to minimize acid regurgitation;
* stop smoking and drinking alcohol.
