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| | Hiatus Hernia
 The
hiatus hernia is one of the most misunderstood and maligned conditions in
medicine. People blame this hernia for much more than it ever does. Patients
with a hiatus hernia need to understand what it is and what might occur with it.
Most importantly, they need to know it is unusual for serious problems to
develop from this type of hernia.
Anatomy
The diaphragm is a sheet of muscle that separates the lungs from the
abdomen. When a person takes a deep breath, the dome-shaped diaphragm contracts
and flattens. In doing this, the diaphragm pulls air into the lungs. The left
diaphragm contains a small hole through which passes the tube-shaped esophagus
that carries food and liquid to the stomach. Normally this hole, called a
hiatus, is small and fits snugly around the esophagus. The J-shaped stomach sits
below the diaphragm.
What Causes a Hiatus Hernia?
In some people, the hiatus or hole in the diaphragm weakens and enlarges. It
is not known why this occurs. It may be due to heredity, while in others it may
be caused by obesity, exercises such as weightlifting, or straining at stool.
Whatever the cause, a portion of the stomach herniates, or moves up, into the
chest cavity through this enlarged hole. A hiatus hernia is now present. Hiatus
hernias are very common, occuring in up to 60 percent of people by age 60. 
What Are the Different Types of Hiatus Hernia?
- Sliding Hiatus Hernia -- In this most common type of hiatus hernia,
the herniated portion of the stomach slides back and forth, into and out of
the chest. These hernias are normally small and usually cause no problems or
even symptoms.
- Fixed Hiatus Hernia -- In this case, the upper part of the stomach
is caught up in the chest. Even with this hernia, there may be few symptoms.
However, the potential for problems in the esophagus is increased.
- Complicated or Serious Hiatus Hernia -- Fortunately, this type of
hernia is uncommon. It includes a variety of patterns of herniation of the
stomach, including cases in which the entire stomach moves up in the chest.
There is a high likelihood that medical problems will occur with this hernia
and that treatment, frequently involving surgery, will be required.
Complicated hernias are uncommon.
Symptoms
In most patients, hiatus hernias cause no symptoms. This is especially true
of sliding hernias. When symptoms occur, they may only be heartburn and
regurgitation, when stomach acid refluxes back into the esophagus. Some patients
with fixed hiatus hernias experience chronic reflux of acid into the esophagus,
which may cause injury and bleeding. Anemia, or low red blood cell count, can
result. Further, chronic inflammation of the lower esophagus may produce
scarring and narrowing in this area. This, in turn, makes swallowing difficult,
and food does not pass easily into the stomach.
Does Hiatus Hernia Cause Pain and Indigestion?
It is wrong to always blame a hiatus hernia for pain and indigestion. Hiatus
hernias generally do not cause acute pain. This symptom may result from other
disorders, such as peptic ulcers or even heart disease. Some patients with
coronary heart disease fool themselves into believing their discomfort is due to
a hiatus hernia. If upper-abdominal pain or indigestion occurs, people should
not mislead themselves into thinking the cause is a hiatus hernia. Instead, the
patient should seek medical advice.
Diagnosis
Diagnosis of a hiatus hernia is typically made through an upper GI barium
x-ray. A complementary test is gastroscopy, or upper-intestinal endoscopy, in
which the physician visually examines the esophagus and stomach using a flexible
scope while the patient is lightly sedated.
What Are the Complications?
The complications of hiatus hernia are:
 | Chronic heartburn and inflammation of the lower esophagus, called reflux
esophagitis
| Anemia due to chronic bleeding from the lower esophagus
| Scarring and narrowing of the lower esophagus causing difficulty in
swallowing
| While sleeping, stomach secretions can seep up the esophagus and into the
lungs causing chronic cough, wheezing, and even pneumonia |
| | |
In addition, the complicated hernia can cause serious problems such as
difficulty in breathing or severe chest pain, especially in the elderly.
Treatment
Treatment is called for only when the hernia results in symptoms, such as
persistent heartburn or difficulty in swallowing. Acid inflammation and
ulceration of the lower esophagus also require treatment.
General guidelines for treating heartburn and esophagitis (inflammation of
the esophagus) are:
| Avoid (or use only in moderation) foods and substances that increase
reflux of acid into the esophagus, such as:
 | nicotine (cigarettes)
| caffeine
| chocolate
| fatty foods
| peppermint
| alcohol
| spearmint |
| | | | | |
| Eat smaller, more frequent meals and do not eat within 2-3 hours of
bedtime.
| Avoid bending, stooping, abdominal exercises, tight belts, and girdles all
of which increase abdominal pressure and cause reflux.
| If overweight, lose weight. Obesity also increases abdominal pressure.
| Prescription medications. Certain drugs, such as intestinal
antispasmodics, calcium channel blockers, and some antidepressants weaken
the muscle strength of the lower espohagus.
| Elevate the head of the bed 8 to 10 inches by putting pillows or a wedge
under the upper part of the mattress. Gravity then helps keep stomach acid
out of the esophagus while sleeping. |
| | | | |
Other Treatments
Drugs -- Some medicines effectively reduce the secretion of stomach
acid, while others increase the muscle strength of the lower esophagus,
thereby reducing acid reflux.
Surgery -- The complicated hiatus hernia requires surgery
occasionally on an emergency basis. Surgery otherwise is reserved for those
patients with complications that cannot be handled with medications. The mere
presence of a hiatus hernia is not a reason for surgery.
Summary
A hiatus hernia is an extremely common condition which usually does not
cause symptoms or problems. However, when it does, the physician can frequently
treat the problem effectively with a well-planned program. Surgery is
infrequently required to treat a hiatus hernia.
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