A Surgeon’s Perspective
Learn about the causes, symptoms, and treatment options for hiatal hernias, a common condition that affects many people. Discover how surgery and PPI medications are used to help manage acid reflux and GERD symptoms.
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Dr. Steve R Siegal MD, FACS 5/7/2023
What is a Hiatal Hernia?
A hiatal hernia is a medical condition that occurs when the upper part of your stomach bulges through your diaphragm into your chest cavity. The stomach normally lives within the abdominal cavity, below the diaphragm, The diaphragm is the muscle that separates your chest from your abdomen, and it plays a vital role in breathing. Hiatal hernias are very common. In fact, there is already a natural hole in the diaphragm that allows the esophagus to travel from the chest into the abdomen. It is the progressive laxity of this hole and widening that allows the stomach to migrate into the chest.
Symptoms of Hiatal Hernia
The symptoms of hiatal hernia can vary from person to person, and some people may not experience any symptoms at all. Common symptoms include:
– Acid reflux
– Chest pain
– Difficulty swallowing
– Shortness of breath
Causes of Hiatal Hernia
The exact cause of hiatal hernia is unknown. However increased pressure in the abdominal cavity leads to pushing intestinal contents outside of the abdomen. This coupled with changes in the connective tissue protecting against herniation likely leads to hernia formation. Several factors may increase your risk of developing the condition. These include:
– Chronic cough
– Straining during bowel movements
Diagnosis of Hiatal Hernia
A hiatal hernia can be diagnosed two way. It can be seen on imaging studies, for example X-Ray, Upper GI studies, or CT scans. It can also been diagnosed during an upper endoscopy.
Treatment of Hiatal Hernia
Often times hiatal hernias are found ‘incidentally,’ meaning found on imaging but the patient experiences no symptoms. If you have a small hernia and no symptoms, these can be left alone. However if you are experiencing any of the above symptoms, treatment is recommended. If you have a small hernia and acid reflux (GERD) you can be treated with medications (PPIs).
Medications for Hiatal Hernia
Proton pump inhibitors (PPIs) are a type of medication that can help manage acid reflux and GERD symptoms. These medications work by reducing the amount of acid produced in your stomach. PPIs are available over-the-counter and by prescription, and they are generally safe and well-tolerated.
There is a big caveat to this:
As long as you have a hiatal hernia, you will always regurgitate or reflux fluid up the esophagus! Once you develop a hernia, the mechanisms to protect from refluxing are gone. PPIs merely turn down the acidity of the refluxing fluid!
Surgery for Hiatal Hernia
If medications no longer control your symptoms, or worse, you have developed acid reflux damage (esophagitis or Barrett’s esophagus) then hiatal hernia repair is recommended. Additionally, if you are concerned about long term PPI use, then repair is recommended.
Remember, not a single type of hernia will go away on its own. There is only one treatment for any type of hernia and that is surgical repair!
There are two main parts to surgery: 1) repair of the hiatal hernia and 2) the anti-reflux mechanism. Hiatal hernia repair is straight forward and includes repairing the gap in the diaphragm after returning the stomach to the abdomen. The anti reflux mechanism can be re-established via a fundoplication or a LINX device.
Lifestyle Changes for Hiatal Hernia
In addition to medication and surgery, making lifestyle changes can help manage your hiatal hernia symptoms. These changes include:
– Losing weight
– Quitting smoking
– Eating smaller, more frequent meals
– Avoiding trigger foods and drinks
– Elevating the head of your bed
– Waiting at least two hours after eating before lying down
Hiatal hernia is a common condition that affects many people. Although the symptoms can be uncomfortable and disruptive, there are many treatment options available to manage the condition. If you are experiencing symptoms of hiatal hernia, come see us to discuss the best course of action for your specific situation.