Hiatus Hernia

What is a hiatus hernia?

To understand what a hiatus (or hiatal) hernia is, first you need to understand some normal anatomy of the upper gastrointestinal tract. Your chest cavity and abdominal cavity are separated by a thin flat muscle wall called the diaphragm, which runs somewhat horizontally approximately at the level of the bottom of your rib cage. Ordinarily, the oesophagus lies within the chest cavity (above the diaphragm) while the stomach lies within the abdominal cavity (below the diaphragm). The oesophagus and stomach join together at the oesophago-gastric junction (OGJ or GOJ), which usually lies within a small opening in the diaphragm, called the hiatus.

A hiatus hernia refers to the situation where the top of the stomach has herniated (pushed through) the hiatus, so that a portion of the top of the stomach lies within the chest cavity instead of being completely within the abdominal cavity. 

 

How common is hiatus hernia?

The exact prevalence of hiatus hernia is difficult to quantify because there is some subjectivity in the diagnostic criteria, and because many patients with a hiatus hernia may go undiagnosed because of lack of symptoms. Therefore, there are widely varying reported estimates of prevalence, ranging from 10-80% of the adult population in Western countries. What we do know for certain is that hiatus hernia is a very common condition.  

 

Types of hiatus hernia

There are two main subtypes:

  • Sliding hiatus hernia: This is by far the most common type, accounting for 85-95% of all hiatus hernia. In sliding hiatus hernia, the hiatus dilates allowing the stomach to herniate upward. Mobility means that sliding hiatus hernia can be intermittent, especially when small.

  • Para-oesophageal hernia: Much less common, accounting for 5-15% of all hiatus hernia. Here the oesophagus and oesophago-gastric junction remains in its correct position, while part of the stomach herniates adjacent to this. Most para-oesophageal hernias also have a sliding component.

 

What are the risk factors for developing hiatus hernia?

Age and obesity are the two most important risk factors for developing hiatus hernia:

  • Age: With age, there is weakening and loosening of the ligaments holding the hiatus (opening of the diaphragm) in place. This predisposes to herniation occurring.

  • Obesity: Overweight and obesity are very closely linked to the risk of hiatus hernia developing. This is because obesity causes increases pressure within the abdominal cavity, which tends to make the stomach push through the hiatus (opening in the diaphragm) into the chest. There is a linear relationship of excess weight with risk of hiatus hernia (that is, every kilogram of excess weight increases your risk of developing a hiatus hernia). Belly fat is especially likely to cause hiatus hernia.

  • Other causes of increased intra-abdominal pressure: If occurring over a long time, any factor that persistently raises the pressure within the abdominal cavity could contribute. Such factors include chronic cough, straining, heavy lifting or tight waistbelts.

 

What are the implications of a hiatus hernia? Is it dangerous?

In general, no, hiatus hernia is not a dangerous condition. Many patients may have a hiatus hernia without even realising it, and it often does not cause any symptoms. The main significance of a hiatus hernia is that it disrupts the anti-reflux barrier between the oesophagus and stomach, making it more likely for the patient to experience gastro-oesophageal reflux disease (GORD). However, not everybody with hiatus hernia will develop reflux.

 

What are the symptoms and signs of hiatus hernia?

  • It is important to be aware that many persons with hiatus hernia will have no symptoms at all. 

  • Simple sliding hiatal hernias do not directly cause symptoms. However, by predisposing to gastro-oesophageal reflux they can lead to symptoms such as heartburn and regurgitation.

  • Rarely, large paraoesophageal hernias can directly lead to symptoms from mechanical obstruction or twisting of the herniated stomach (volvulus). This may present with symptoms such as difficulty swallowing, vomiting, chest or upper abdominal pain.

  • Occasionally, large hiatus hernias can lead to bleeding and anaemia as a consequence of friction and rubbing leading to Cameron’s erosions

 

Diagnosis of hiatus hernia

Identification of large hiatus hernias is straightforward. However, small hernias are often intermittent and therefore not always easy to identify by any method. This is the reason why a hiatus hernia is visible on one test and not another. Nevertheless there are 3 main tests ordinarily used to identify a hiatus hernia:

  • Endoscopy: At endoscopy, a sliding hiatus hernia can be diagnosed when the top of the stomach is visualised to be at least 2cm above the hiatus (opening in the diaphragm). Endoscopy has the advantage of providing information on structural abnormalities, reflux related inflammation, Cameron’s erosions leading to blood loss

  • Barium swallow: A type of x-ray where the patient is asked to swallow contrast dye, which provides better definition of the oesophagus and stomach. 

  • High resolution oesophageal manometry and reflux pH monitoring: Manometry measures the pressures with in the oesophagus and OGJ, and can identify the presence of a hiatus hernia. Reflux pH monitoring is carried out in conjunction with manometry, and measures the quantity of acid reflux that occurs over a 24h period.

 

Not all of these tests are required in all patients, and the choice of testing is guided by the type and severity of the patient’s symptoms. In particular, barium swallow, manometry and pH testing may only be required in those patients in whom surgery is being considered.

 

Treatment of hiatus hernia

Since hiatus hernia is not of itself a dangerous condition, the treatment of hiatus hernia is entirely dependent on the symptoms it is producing:

  • No symptoms: no treatment or monitoring is required

  • Reflux symptoms: Treatment is directed at the reflux, including dietary and lifestyle modification, weight loss and medications. In general, the management of patients with hiatus hernia and reflux is largely the same as those with reflux in the absence of hiatus hernia. However, in the presence of a hiatus hernia, especially a large one, there may be greater benefit from anti-reflux surgery.

  • Symptoms of mechanical obstruction from a para-oesophageal hernia: Medications are ineffective in this situation. If mild symptoms of swallowing difficulty, then patient can compensate by altering the diet to avoid hard, chunky foods. However in most cases, such symptoms can only be relieved by surgery to repair the hernia.

  • Blood loss: If mild, you may be commenced on iron supplementation, but for more significant bleeding a blood transfusion may be required. If blood loss becomes persistent and problematic, this may be an indication to perform surgery to repair the hernia.

 

Diet for hiatus hernia

There is no ‘one size fits all’ diet for hiatus hernia. The dietary recommendation is different depending on the types of symptoms that are being experienced by the patient:

  • No symptoms: no change to diet is necessary

  • Reflux symptoms: Follow the usual dietary guidelines for GORD. These include ‘grazing’ on smaller, more frequent meals, avoiding eating for 3h before bedtime, and avoiding any of your obvious trigger foods. These trigger foods can be different from person to person, but common triggers include coffee, chocolate, alcohol, peppermint, fizzy drinks, spicy food and alcohol. 

  • Symptoms of mechanical obstruction with para-oesophageal hernia: Avoid hard, chunky foods and stick to soft, mushy, well lubricated foods.

 

Surgery for hiatus hernia

It is important to be aware that the majority of patients with hiatus hernia do not require surgery. Surgery is usually considered in the following situations:

  • Significant reflux symptoms that are not responsive to diet, lifestyle modifications or medication; or where the patient is intolerant of medications

  • Para-oesophageal hernia with obstruction leading to difficulty swallowing, pain and vomiting

 

Nowadays, hiatus hernia surgical repair is usually performed via laparoscopy (keyhole surgery). This results in a quicker recovery time. Nevertheless, there are always risks of complications with any surgery, and particular to this operation there are risk of post-operative swallowing difficulty, abdominal bloating, damage to the oesophagus, nerves supplying the stomach, and injury to the spleen. Therefore, the decision to undertake surgery should not be taken lightly, and such patients should be first assessed by an oesophageal specialist to ensure that they are likely to benefit from surgery.

Who manages patients with hiatus hernia in Sydney?

Ensure you are in the care of an expert in oesophageal diseases who can interpret oesophageal investigations and provide you with personalised advice regarding the advantages and disadvantages of all the treatment options. Contact Dr Santosh Sanagapalli to arrange a consultation and assessment today.

Trusted Gastroenterologist based at St Vincent's Hospital campus, Darlinghurst.

Expert care in all aspects of gastrointestinal health with subspecialty expertise in disorders of the oesophagus.

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