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What is Hiatus Hernia?
Hiatus hernia is a common diagnosis of the upper digestive system that can affect individuals with varying degrees of severity.
To understand this disorder it is helpful to learn normal anatomy and the abnormal changes that produce this condition. The diaphragm is a thin, flat muscle separating the chest from the abdomen. It regulates respiration by moving up and down. For any structure to pass through the diaphragm, there must be an opening, referred to as a hiatus.
The esophagus, a muscular tube, propels food from the mouth to the stomach with regular contractions. It runs through the chest, behind the lungs and heart, and through the tight esophageal hiatus in the diaphragm to enter the stomach. Normally, the hiatus is reasonably tight and grips the esophagus just above the stomach. At this point, the esophagus wall is thicker and a muscle at this site contracts, forming the lower esophageal sphincter (LES). After swallowing, the LES opens, allowing food passage through to the stomach and then it usually closes quickly, staying in a closed position, and preventing food or acid in the stomach from refluxing back up into the esophagus.
In some people, for reasons not yet fully understood, the opening in the diaphragm becomes wider than usual. When this occurs, the lower esophagus is out of normal position and the upper part of the stomach pushes up through the enlarged opening, producing a hiatus hernia. Commonly, a portion of stomach moves up and down through the hiatus, producing a sliding hiatus hernia.
What are the symptoms of hiatus hernia?
The most common symptom of hiatus hernia is heartburn, the burning discomfort produced in the lower central chest by refluxing stomach acid irritating the lower esophagus, which lacks the protective mucous lining of the stomach.
Symptoms vary from person to person, and can include food regurgitating into the mouth, a bitter taste, or bad breath. The symptoms can be similar to those experienced by individuals with gastroesophageal reflux disease (GERD). Coughing is often a result of irritation to the throat, which may also trigger a spasm in the esophagus with more severe, extensive chest pain. Many people have no symptoms from hiatus hernia or just a few symptoms, which arise during activities that increase pressure against the diaphragm, such as lying down or bending.
How is a hiatus hernia treated?
The first aim of treatment is to prevent the refluxing of acid into the esophagus. Consuming small, frequent meals instead of large ones lessens the degree of stomach distension, thus decreasing upward pressure. Squatting, rather than bending, and elevating the head of the bed by about 8 inches while sleeping, both reduce pressure on the diaphragm, so these measures may help. Being overweight increases intra-abdominal pressure, so maintaining average weight might also be beneficial. Patients should avoid smoking, which relaxes the LES and allows for reflux.
The second aim of treatment is to reduce stomach acid so that the contents are less irritating if reflux does occur. Do this by avoiding long periods without food in the stomach; avoiding substances that stimulate acid secretion, such as aspirin and alcohol; and by taking appropriate medication. Eliminate or reduce eating foods that cause you discomfort. These vary from person to person. Some medications and supplements may aggravate symptoms; consult your doctor or pharmacist for more information.
Two main pharmacological approaches to treating hiatus hernia with medications are neutralizing acid and blocking acid production.
Neutralize acid: Many people find that non-prescription antacids (which neutralize acid in the esophagus and stomach) can provide quick, temporary, and/or partial relief. Antacids are short acting and do not prevent heartburn. Over the counter antacid medication such as Maalox®, Tums®, and Rolaids® may help initially. If you find the need for antacids for more than 3 weeks, then consult a physician.
Block acid production: If the above milder measures do not work for you, there are some other options. These two classes of medication block acid production.
H2-RAs work by blocking the effect of histamine, which stimulates certain cells in the stomach to produce acid. These include cimetidine (Tagamet®), ranitidine (Zantac®), famotidine (Pepcid®), and nizatidine (Axid®). H2-RAs are all available as prescription medications and some are available in a lower dose, over-the-counter without a doctor’s prescription.
Proton pump inhibitors (PPIs) are a newer class of medication. They work by blocking an enzyme necessary for acid secretion. These include omeprazole (Losec®), lansoprazole (Prevacid®), pantoprazole (Pantoloc®), esomeprazole (Nexium®), and rabeprazole (Pariet™). In Canada, these medications are available only with a prescription. PPIs have emerged as the most effective therapy for relieving symptoms and improving quality of life, as well as healing and preventing damage to the esophagus in people with hiatus hernia.
Treatments that reduce reflux by increasing LES pressure and downward esophageal contractions are metoclopramide and domperidone maleate (Motilium®).
All of the medications discussed above have specific treatment regiments, which you must follow closely for maximum effect. Usually, a combination of these measures can successfully control the symptoms of a hiatus hernia. If not, PPI maintenance may be the answer, or surgery, such as fundoplication, may be tried; however, these measures may be only partially effective.
Are you taking prescription medication for any of the following stomach problems/symptoms:
Stomach pain or discomfort
Heartburn
Sour taste in mouth/acid regurgitation
Excessive burping/belching
Increased abdominal bloating
Nausea
Early satiety
If you answer yes to any one of the symptoms listed above then take this test to see if your current medication is adequately controlling your stomach symptoms.
The PASS Test
PPI* Acid Symptom Suppression Test
*PPI is short for proton pump inhibitor, a class of medication used to suppress the acid in your stomach. These include Losec®, Nexium®, Pantoloc®, Pariet™, and Prevacid®.
