What are Hiatal Hernias?

A hiatal hernia is medical conditions in which part of your stomach bulges into your chest cavity. Hiatal hernias are common, especially in older adults. Some people with a hiatal hernia do not know they have one unless their doctor discovers it incidentally while diagnosing or imaging another problem. Other people experience symptoms, such as heartburn. Doctors use imaging to detect hiatal hernias, and can suggest a course of treatment for patients whose hiatal hernias pose a problem.

A hiatal hernia is a condition in which the upper part of your stomach bulges through your diaphragm, which is a large, thin muscle that lies between your abdomen and your chest. Your diaphragm helps you breathe and it helps prevent acid from coming up into your esophagus, which is the tube that connects your mouth to your stomach.

Normally, your stomach sits below your diaphragm. If you have a hiatal hernia, your stomach pushes through a small opening in your diaphragm, which makes it easier for acid to move upward (reflux) into your esophagus. Doctors refer to this leaking of stomach acid into your esophagus as gastroesophageal reflux disease (GERD).

GERD can cause a variety of symptoms, including:

• Heartburn
• Problems swallowing
• Nausea and/or vomiting
• Bad breath
• A dry cough
• Breathing problems
• Erosion of tooth enamel, particularly on back teeth

People of all ages and both genders can develop a hiatal hernia, but it occurs more frequently in people over the age of 50. Hiatal hernia seems to occur more often in smokers and in overweight individuals.

A hiatal hernia is often the result of an increase in pressure in the abdominal cavity, which is the space in the middle of your body that holds your stomach, liver, pancreas, gallbladder, spleen, intestines, kidneys and bladder. Pressure can build up from severe coughing, vomiting, straining to have a bowel movement, and from heavy lifting or other physical strain. Pregnancy, obesity, and extra fluid in the abdomen can also cause a hiatal hernia. While there is a link between hiatal hernia and GERD, one condition does not seem to cause another.

There are two types of hiatal hernias:

1. Sliding hiatal hernia – the stomach and the section of the esophagus adjoining the stomach slide up through the hiatus into the chest
2. Paraesophageal hernias – the stomach and esophagus stay in their normal locations, but part of the stomach squeezes through the diaphragm to sit beside the esophagus

Paraesophageal hernias are less common than sliding hernias, but more concerning because squeezing through the diaphragm in this way can “strangle” the stomach tissue – without causing any symptoms. Because of this, paraesophageal hernias present a greater risk for progressing to incarceration, where the section of the stomach stuck through the diaphragm causes an obstruction, or ischemia in which blood supply to that section of the stomach is cut off. Incarceration and ischemia associated with hiatal hernias may require emergency surgery. 

Diagnosis and Treatment of Hiatal Hernias

Doctors use imaging to detect and diagnose hiatal hernias. They frequently use upper GI series, also known as a barium swallow, to visualize the structures of your stomach and diaphragm. Just prior to the test, you will drink about one and a half cups of a barium solution, which has nearly the same thickness as a milkshake.

About 30 minutes later, you will lie on a table and undergo a series of x-rays; the barium solution coats the esophagus and stomach to make the organs easy to see on the x-rays. In some cases, you may need to drink more barium solution as they take x-rays. The radiology team may tilt the table as you drink the barium.

When radiologists look at the x-rays of people with hiatal hernia, they can see the upper part of the stomach sitting protruding into the chest cavity, where it isn’t supposed to be. There may or may not be air in the hernia.

Treatment for hiatal hernia 

Your hiatal hernia may not need treatment if it does not cause any signs or symptoms, such as recurrent heartburn or acid reflux. If you do experience these signs or symptoms, your doctor may recommend antacids to neutralize the acid, medications to reduce the production of acid, or medications that block the production of stomach acid and heal the esophagus. Dietary changes, weight loss, and other lifestyle changes can help.

Treating hiatal hernias may require surgery in cases where medications do not help. Surgical treatment may also be required in patients experiencing complications of hiatal hernia and GERD, such as severe inflammation or narrowing of the esophagus.

Surgery may involve pulling your stomach down into your abdomen and reducing the size of the opening in the diaphragm. It may be necessary to reconstruct the esophageal sphincter, which is a muscle that separates the esophagus from the stomach and acts like a valve to prevent stomach acid from refluxing into the esophagus.

For more information about hiatal hernias and their imaging, speak with your physician or radiologist. While most hiatal hernias never cause a problem, it is always worthwhile knowing if you have this condition.