Description, causes, prevention, treatment and medicines
A hernia is when part of the body bulges or protrudes into another part of the body that would not normally contain it. In the case of a hiatus hernia, a part of the stomach, normally in the abdomen, slides or protrudes into the chest cavity.
Normal anatomy
The chest and abdomen are normally separated by the diaphragm, a thin sheet of muscle that aids in breathing. The oesophagus (the tube that food passes down from the mouth to the stomach) goes down through the chest, passing through a small opening (called a hiatus) in the diaphragm and entering the abdominal cavity to join the stomach.
Hiatus hernia
When a hiatus hernia occurs, a portion of the stomach is able to slide upwards through the opening in the diaphragm, beside the oesophagus, into the chest.
There are 2 main types of hiatus hernia.
Sliding hiatus hernia: this is the most common type of hiatus hernia, accounting for about 90 per cent of cases. It occurs when the junction between the oesophagus and the upper part of the stomach protrude up through the oesophageal opening in the diaphragm into the chest cavity. The herniated portion of the stomach can slide back and forth, into and out of the chest.
Rolling hiatus hernia: this is sometimes called a para-oesophageal hiatus hernia. In this case, the junction of the oesophagus and stomach stays down within the abdomen, and the top part of the stomach (the fundus) bulges up into the chest cavity. This type of hernia normally remains in one place, sitting next to the oesophagus, and does not move in or out when you swallow.
hiatus hernia
Hiatus hernias often don’t cause symptoms but may cause or contribute to:
- pain in the abdominal area;
- heartburn;
- pains in the chest area; and
- swallowing difficulties.
However, these can also be the symptoms of a number of other conditions such as peptic ulcer and even heart disease. Always remember that your doctor needs to investigate any chest pain or swallowing difficulties you experience.
Who gets hiatus hernia?
Hiatus hernias are relatively common, occurring in about 10 per cent of the population. Often they are very small and people who have them don’t know it, as they don’t feel any symptoms or discomfort.
Most hiatus hernias are seen in adults, and about 30 per cent of people over the age of 50 will have a hiatus hernia, although they may not know about it. Women are affected more often than men. Hiatus hernias are often seen in people who are overweight and in pregnant women.
What causes a hiatus hernia?
Hiatus hernias can occur when there is weakening of the muscle tissue around the gap where the oesophagus passes through the diaphragm or where this gap is otherwise stretched.
A number of risk factors appear to contribute to hiatus hernias developing including:
- hereditary factors;
- age;
- obesity;
- pregnancy;
- sudden, hard physical exertion, such as lifting;
- a birth defect; and
- trauma or surgery to the abdominal area.
Symptoms
Most hiatus hernias don’t cause any problems. In fact, many people with small hiatus hernias have no symptoms at all and may never know they have the condition unless it is discovered by accident as part of an investigation for another problem. However, moderately-sized or large hiatus hernias are more likely to cause symptoms and discomfort.
Common symptoms
The most common symptoms of hiatus hernia are those arising from gastro-oesophageal reflux, which can occur as a result of the hernia.
These symptoms include:
- heartburn, which is a painful burning sensation felt in the lower front chest area behind the breastbone and upper abdomen, often after eating or when lying down; and
- regurgitation of sour or bitter-tasting acid fluid into the mouth, particularly at night, which occurs with more severe reflux.
These symptoms are often worse when you bend over, lie down or strain to lift heavy objects.
Depending on the type of hiatus hernia, other symptoms can include:
- belching or burping;
- difficulty in swallowing; and
- pain on swallowing (especially hot drinks).
Symptoms often occur in people aged over 50 years, overweight people and pregnant women.
Complications of hiatus hernia
Severe reflux
In some people with hiatus hernia, the acidic stomach contents regurgitate (reflux) regularly into the oesophagus. In severe cases, ongoing reflux may cause damage to the oesophagus and even bleeding that may lead to anaemia in some cases. Ongoing reflux may cause injury to the oesophagus and a narrowing of the oesophagus (called a stricture) that can cause swallowing difficulties.
In addition, long-term gastro-oesophageal reflux disease can cause changes to the cells in the lining of the lower oesophagus — a condition known as Barrett’s oesophagus. Having Barrett’s oesophagus puts you at increased risk of oesophageal cancer.
Strangulation
A rolling or para-oesophageal hiatus hernia is one in which the top part of the stomach (fundus) bulges into the chest through the oesophageal opening in the diaphragm. A rare complication of rolling hiatus hernias is a condition known as strangulation. This is where the protruding part of the stomach becomes twisted or pinched by the diaphragm. This can cause bloating, blockage of the oesophagus or problems swallowing. Very rarely, the blood supply to the stomach can become blocked, and this can cause severe chest pain and breathing difficulties. This is a medical emergency and surgical treatment is needed immediately.
Difficulty breathing
Sometimes with large hiatus hernias there is so much of the stomach protruding up through the oesophageal gap in the diaphragm that it presses on your lungs and can make breathing more difficult. See your doctor if you are having difficulty breathing.
The outlook
In most cases, symptoms from a hiatus hernia can be kept under control with medicines and lifestyle and dietary changes to treat gastro-oesophageal reflux — your doctor can help you with these.
Other treatment, such as surgery, is normally only required if your symptoms become worse and more constant. Rolling, or para-oesophageal, hernias are more likely to require surgery than sliding hiatus hernias.