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Hiatal Hernia and Heartburn

Heartburn

Heartburn, also known as gastroesophageal reflux disease, or GERD, is a very common condition. For most people it is a mild problem that rarely requires medication. For some, however, it is a serious and even debilitating problem that can significantly affect quality of life. GERD is often due to malfunction of the valve between the esophagus and stomach (the lower esophageal sphincter or LES) and/or a hiatal hernia.

Hiatal Hernia

Your chest is separated from your abdomen by a dome-shaped sheet of muscle called the diaphragm. The esophagus passes through an opening in the diaphragm called the hiatus.

When the tissue around the hiatus weakens, part of the stomach may protrude through the opening into the chest cavity. This is called a hiatal hernia. Weakening of the anchoring tissues of the gastroesophageal junction leads to a hiatal hernia.

Hiatal hernias are very common. The majority of small hernias produce no symptoms.

Symptoms

Symptoms may be caused by a hiatal hernia and/or malfunction of LES. The LES acts like a valve to the stomach, remaining closed until swallowing causes it to briefly open. If the LES is weak and allows stomach acid to reflux back into the esophagus, it will cause irritation of the lining and a burning sensation.

Typical symptoms include heartburn and regurgitation when stomach acid refluxes back into the esophagus. Some patients may experience esophagitis, or irritation of the esophagus caused by acid that erodes through the lining. Bleeding caused by this erosion may lead to anemia. Further chronic erosion may lead to stricture, or narrowing that makes swallowing difficult. Respiratory symptoms such as asthma, chronic cough, bronchitis, or recurring pneumonia can be caused by aspiration of stomach acid during sleep. Chronic irritation of the esophagus can also lead to Barrett's esophagus, a precancerous condition, or eventually to cancer.

Types of Hiatal Hernias

Sliding Hiatal Hernia: In this most common type of hernia, the herniated portion of the stomach slides back and forth, into and out of the chest. This type of hernia is least likely to cause symptoms.

Fixed Hiatal Hernias: With a fixed hiatal hernia, the upper portion of the stomach remains permanently trapped or stuck in the chest cavity.

Paraesophageal Hernia: This type of hernia is unusual. However, it is very prone to "strangulation" and may need to be repaired to prevent the need for emergency surgery.

Diagnosis

Diagnosis of the hiatal hernia is typically made by a barium swallow x-ray study. Upper GI endoscopy (examination of the stomach and esophagus with a flexible scope) should be done to evaluate the extent of damage to the esophagus and look for other conditions that may mimic hiatal hernia. Pressure measurements (esophageal manometry) can be done to evaluate the function of the lower esophageal sphincter and the rest of the esophagus. In some cases a probe is placed (24 hour pH study) to measure the amount and frequency of acid reflux into the esophagus.

Treatment

Treatment is called for only when the hiatal hernia results in symptoms. Reflux is treated in three stages: lifestyle changes, drug therapy and surgery.

Lifestyle changes

  • Avoid things that cause reflux or increase stomach acid such as: tobacco, fatty foods, alcohol, caffeine, chocolate, peppermint, and spearmint.
  • Eat smaller, more frequent meals and do not eat within 4 hours of bedtime.
  • Avoid bending, stooping, sit-ups, and tight clothing.
  • If overweight, lose weight. Obesity increases abdominal pressure.
  • Certain drugs such as intestinal antispasmodics, calcium blockers, and some antidepressants can cause reflux.
  • Elevate the head of the bed 6-8" with blocks. Gravity helps keep the stomach acid out of the esophagus.

Drug Therapy

  • Antacids such as Tums, Mylanta
  • Acid-blocking drugs such as Zantac, Tagamet, or Pepcid
  • Reglan
  • Proton pump inhibitors such as Prilosec, Prevacid, Aciphex, and Nexium

Surgical Therapy

Patients who do not respond well to medical therapy or who do not wish to take medication for the rest of their lives may be considered for surgical correction of their reflux problem. This is known as fundoplication. This procedure involves creating a new valve by wrapping the upper portion of the stomach around the esophagus and repairing the hiatal hernia. It is most commonly done with a technique called laparoscopy in which the surgery is done through small incisions with the help of a camera.