Hiatal Hernia

A hiatal hernia occurs when the opening between the abdomen and chest (diaphragm) is too large, causing a part of the stomach to slip up into the chest cavity. The condition can result in heartburn and other issues, and doctors typically suggest surgery if medications don't work.

In the sections below, we take a closer look at hiatal hernia, its causes, and its surgical treatment options.

What Is Hiatal Hernia

The muscles in your body hold your organs in place, and when one of the muscles develops a weak spot, the organ or intestine can protrude through. This is what causes hernias. A Hiatal hernia is an abnormal bulge in your stomach caused by a part of your stomach pushing up into an opening of the diaphragm. A diaphragm is a muscular structure between your stomach and chest that facilitates breathing in the body.

In a hiatal hernia, the portion of your stomach below the diaphragm moves into your chest, pinching the upper part of it. When this happens, the stomach acid can flow upwards via the muscle opening, causing heartburn and other serious issues. 

Typically, a hiatal hernia develops as a result of increased pressure in the abdominal cavity. This can occur due to the following reasons:

• Severe coughing and vomiting 
• Engaging in intense physical activities
• Obesity

In some cases, a hiatal hernia can also develop during pregnancy. 

Symptoms of Hiatal Hernia

There is a wide range of symptoms associated with hiatal hernias depending on their size. Small hiatal hernias might not show any symptoms at all. In some cases, the symptoms of hiatal hernia include heartburn, bloating, and a bitter taste in the back of the throat, which are similar to those of gastroesophageal reflux disease (GERD). 

Additionally, you might also experience trouble swallowing, feel overly full after eating medium-sized meals, or feel chest pain if you have a hiatal hernia. 

When Should You See a Doctor

You should immediately contact your doctor if you experience one or more of the following symptoms:

• Intense pain in the chest or abdomen
• Feeling nauseous for a long period of time
• Experiencing issues with bowel movements
• Problems passing gas

Diagnosis

The diagnosis of a hiatal hernia often occurs during a procedure or test to determine the cause of heartburn or abdominal pain. Here are some most common ways of diagnosing hiatal hernia:

• X-ray - during this procedure, the patients are asked to consume a special liquid that fills the lining of their digestive tract. It is done so that some parts of the body appear more clearly on an X-ray. Radiologists will be able to see how you swallow and how it affects different parts of your body. Also, it shows the size of the hiatal hernia and whether the hernia is causing stomach twisting.
• Upper endoscopy - In this procedure, a person's digestive tract is examined non-surgically. Endoscopes, which are flexible tubes with a light and camera attached, allow your doctor to view images of your digestive tract on a television. An upper endoscopy involves passing an endoscope through the mouth, throat, and esophagus to examine the esophagus and stomach.
• Esophageal manometry - The esophageal manometry test evaluates coordinated muscle movements when swallowing. This test involves the use of a catheter, a flexible tube with a narrow tip that measures the pressure generated by the muscles in the esophagus and the valves in each segment.

Treatment Options

If the hiatal hernia is small, it can be managed without surgery. In cases where a hiatal hernia is associated with GERD, treatment typically involves treating GERD with lifestyle changes, such as:

• Staying away from fried foods
• Scheduling proper meal times (no snacking)
• Avoiding smoking 
• Maintaining a healthy weight

In case you are experiencing hiatal hernia symptoms like heartburn or acid reflux, your doctor is likely to prescribe you the following, depending upon your condition:

• Medicines to neutralize the stomach acid
• Medicines to lessen the production of stomach acid
• Medicines to block the production of stomach acid to heal the esophagus 

In contrast, if you have a paraoesophageal hernia (a section of your stomach pushing through the hiatus), it may strangle your stomach, cutting off the blood supply, so surgery may be necessary. In cases such as this, simply taking medicines will not make a difference. Patients with hiatal hernias having severe, long-lasting (chronic) esophageal reflux who cannot be treated medically may also require surgery.

In order to treat a hiatal hernia, three types of surgery are available: Nissen fundoplication, open repairs, and endoluminal fundoplication.

1. Nissen Fundoplication

This is one of the most common surgical procedures used to treat gastroesophageal reflux disease, or GERD, and hiatal hernias. The purpose of this surgery is to tighten and reinforce the sphincter at the top of the stomach, thus preventing stomach acid from rising into the esophagus.

The procedure involves inserting a laparoscope (a microscopic camera attached to a thin tube) into the abdomen, just like a laparoscopy. The surgeon uses the camera to locate the site of the hernia and treat it. There are some advantages to laparoscopic hiatal hernia repairs over other types, such as less pain, scarring, time in the hospital, and quicker recovery.

2. Open Repair Surgery

An open hernia repair involves making an incision in the groin. The surgeon identifies the hernia sac containing the bulge and then pushes it back into the abdomen. Synthetic mesh and stitches are used to strengthen the defect in the muscular wall to avoid the recurrence of the hernia. 

This is the oldest method of treating hernia and has a longer recovery time. 

3. Endoluminal Fundoplication

This is a new procedure that doesn't require incisions. The surgeon passes a flexible tool called an endoscope down your throat and into your esophagus. During surgery, the surgeon tightens the junction between the stomach and esophagus to prevent reflux. There are, however, some limitations to this treatment, and some patients experience hernia recurrence.

Recovery Time

There are different types of anesthesia, and the recovery process will vary accordingly. Feeling discomfort and slight pain after the surgery is quite normal. You will typically be allowed to go home within 24 hours of surgery. 

When you're at home, keep the incisions dry and clean, and follow your healthcare provider’s instructions on how to bathe. Stitches and surgical staples will be removed at the next appointment.

Gradually resuming normal activities is a good idea, but you should avoid intense physical activity until the injury has completely healed.