What is a Hiatal Hernia?

A hiatal hernia is a fairly common issue. It is estimated that between 30-50% of the over 50’s population may have one, with some never experiencing any symptoms. For others, problems will arise from their hiatal hernia and they may require medication, lifestyle changes and even surgery. Luckily, the success rate of surgery for correcting a hiatal hernia is thought to be up to 90%.

What is a hiatal hernia?

A hiatal hernia (or hiatus hernia) occurs when part of a person’s stomach is squeezed into the chest through an opening in the diaphragm; this opening is known as the hiatus.

Your oesophagus (food pipe) is also located here and it is possible that a hiatal hernia lets acid travel the wrong way, from your stomach back upwards. This can cause painful and uncomfortable symptoms including acid reflux and heartburn.

What are the signs and symptoms of a hiatal hernia?

• Heartburn – a painful/uncomfortable burning sensation in the chest (more common after eating, especially spicy or fatty food or if you eat too fast).
• Acid reflux – regurgitating small amounts of food/liquid that burns and tastes bitter.
• Bad breath.
• Excessive gas.
• Bloating.
• Nausea.
• Problems when swallowing.

The more severe symptoms, such as vomiting and chest and abdominal pain, are usually caused as the hiatal hernia grows in size.

People often experience issues with indigestion and may write off their symptoms as nothing to worry about, but it is recommended that you make an appointment to see your GP if:

• Over-the-counter medicines (such as antacids) are not helping.
• Your symptoms are getting worse or have not gone away after three weeks.

You should also seek medical advice if you are experiencing symptoms of indigestion/acid reflux and suffering from any of the following:

• Sudden, unexplained weight loss.
• Frequent vomiting.
• Passing or bringing up blood.
• You have pain in your upper abdomen.
• You are having issues when swallowing.

There is a significant amount of crossover between the symptoms of a hiatal hernia and the symptoms of gastro-oesophageal reflux disease (GORD). This occurs when heartburn/acid reflux becomes chronic or recurrent.

A hiatal hernia can also be an underlying cause of GORD, although there are many other reasons why a person may have problems with acid reflux, which your GP will be able to discuss with you.

What causes a hiatal hernia?

The causes of hiatal hernias are not completely known as anyone can develop one, although some people are thought to be more at risk than others.

It is thought that being born with a larger than normal hiatus may cause a person to develop a hiatal hernia later in life.

Trauma to the area in question or putting undue strain on the muscles may also lead to a hiatal hernia developing.

This could be from:

• Lifting heavy objects at work.
• Chronic coughing.
• Straining during vomiting/bowel movements.
• Strenuous exercise.
• Surgery.
• An accident.

People with a weakened diaphragm are at a higher risk of developing a hiatal hernia, especially if combined with any of the above risk factors which can increase abdominal pressure.

What are the risk factors for a hiatal hernia?

Hiatal hernias are most common in those who are over 50 years of age. You are also thought to be more at risk from a hiatus hernia if:

• You are a smoker.
• You are overweight.
• You are pregnant.

Diet and lifestyle may also play a part in developing a hiatus hernia (or making symptoms worse), so it is important to eat a varied, balanced diet and avoid fatty, fried and processed foods as well as excessive amounts of sugar or alcohol.

Try switching to decaffeinated drinks or herbal teas and choose low alcohol or alcohol free alternatives. This can also help to improve sleeping patterns – getting enough good quality rest is vital to wellbeing.

Taking regular exercise and limiting stress might also help to reduce the risks of developing the symptoms of a hiatus hernia.

You may want to consider trying:

• Yoga.
• Pilates.
• Walking.
• Mindfulness.
• Meditation.

Sleeping in a slightly elevated position is also thought to decrease the chances of acid travelling from the stomach up to the throat overnight. You may want to adjust your bed or add in an extra pillow so that your head remains at a higher level than your waist at night to see if this gives you any added comfort.

Can a hiatal hernia be prevented?

It is not possible to completely prevent a hiatal hernia. Maintaining a healthy weight and having a good diet and active lifestyle can give you some protection from developing one.

The best advice for preventing a hiatal hernia is to stop smoking, be active and healthy and address any changes in your general health as soon as possible.

What happens if a hiatal hernia is left untreated?

If your hiatal hernia is left untreated this could lead to complications or your condition getting worse. It may also leave you suffering uncomfortable and painful symptoms unnecessarily. This could affect your stress levels and have an impact on your general health and wellbeing.

Very large hiatal hernias can start to affect other organs in the digestive system as well.

If you have persistent acid reflux, inflammation, bloating or any symptoms associated with gastrointestinal issues, you can try taking some over-the-counter medication to relieve your symptoms. You should also make an appointment to speak to a doctor about any concerns you have.

With the less common type of hiatal hernia, sometimes called a rolling hernia, surgery is often required, even in cases where symptoms are minimal. This is because with this type of hiatal hernia, when part of the stomach moves above the diaphragm there is a risk of significant twisting which could result in strangulation. It is therefore necessary to get the right treatment as quickly as possible to prevent injury and even fatality.

Living with a hiatal hernia

Hiatal hernias can usually be controlled with a mixture of medication and dietary changes. More serious instances will usually be treated with surgery.

Over time, you will likely learn what triggers make you feel worse (such as a specific food or drink) and learn to avoid these things.

When living with a hiatal hernia you should always ensure that you keep a supply of any medication that you need to help you with your symptoms on hand, make sure that they are in date and that you know how to administer them. You should also try to make sensible choices regarding your diet, lifestyle and exercise regime.

If you notice unusual changes in your health or find that your symptoms are changing or worsening you should inform your GP immediately.

How is a hiatal hernia diagnosed?

Typically, there are two general categories for hiatal hernias:

• Sliding hiatal hernia – these hernias account for over 80% of cases. They happen when the hernia moves (or slides) up and down, in and out of the chest.
• Paraesophageal hernia – also referred to as rolling hiatus hernias, this happens when a part of the stomach pushes upwards through a hole in the diaphragm, adjacent to the oesophagus. This accounts for up to 15% of hiatus hernia cases.

When you attend your GP appointment, they will want to know about your symptoms as well as your general health. They may also want to perform an examination as well as some tests, so that they can make the correct diagnosis.

To help with this, try keeping a record of the symptoms you have been experiencing and when (for example if they are worse at night or after a heavy meal). Also try to think about whether there have been any other recent changes to your health or lifestyle that precipitated your symptoms.

If your GP refers you to a specialist at the hospital for further investigations, you may typically have:

• An endoscopy – this is where a camera is passed through the body on a long, thin tube and it can take images/videos of your insides.
• A barium swallow – a series of x-rays are taken after the patient swallows a chalky white substance called barium that helps to show up anomalies in the gastrointestinal tract.
• CT scan – this is usually reserved for massive hiatal hernias.
• Chest x-ray – this is the simplest and least invasive test available.

How is a hiatal hernia treated?

Treatments for a hiatal hernia may include any of the following, depending on your health, age and how much the condition is bothering you:

• Dietary and lifestyle changes – this may include cutting down on certain foods or drinks, eating little and often rather than large meals and trying to be healthier, less stressed and taking regular exercise.
• Over-the-counter medication – antacids can help to neutralise stomach acid; they are a common medicine that can be purchased from the pharmacy or supermarket.
• Prescribed medication – medicines known as proton-pump inhibitors (PPIs) are often prescribed to help if OTC medications are not enough. They are some of the strongest inhibitors of stomach acid production available. They include Nexium (esomeprazole), Prilosec (omeprazole) and Prevacid (lansoprazole).
• Surgery – if no other course of action is helping, or if your symptoms are getting worse, your GP may send you for a consultation with a specialist to discuss having an operation to repair the hole in the diaphragm.

Surgery options for a hiatal hernia

If you require corrective surgery for your hiatal hernia, it will most likely be performed as keyhole surgery, also known as laparoscopy. Keyhole surgery allows a surgeon to perform the procedure on a patient’s abdominal area without making any large cuts into their skin.

Instead of using traditional surgical instruments, a small tube that has a camera and light on called a laparoscope is used. This is done under general anaesthetic (while the patient is asleep) and at least one small incision is made to insert the laparoscope, small surgical instruments and a special pump that pumps carbon dioxide gas into the abdomen.

Once the keyhole surgery has been done and the additional gas removed from the body, the surgical wounds are stitched up and dressed. Recovery time is usually faster from keyhole surgery than traditional surgical methods.

After having a laparoscopy to repair a hiatal hernia, patients can usually expect to:

• Spend 2 or 3 nights in the hospital before discharge.
• Return to work after 3–6 weeks.
• Return to their normal diet/eating pattern after 6 weeks.
• Spend several months getting over side effects such as excessive gas and swallowing problems.

As with any surgery, there is a small chance of complications, including infection, as well as the possibility that subsequent surgeries will be needed.

In some cases, open surgery is required. This usually happens when:

• A previous attempt has been made to repair a hiatus hernia.
• The hiatal hernia is large.
• The patient has a history of having surgery performed in the area and has a lot of scar tissue.
• Emergency surgery is required (due to a severe twist causing damage to the stomach or other organs).

Surgery to correct a problematic hiatal hernia will normally consist of the following steps:

• Removal of the sac or lining of the hernia.
• Allowing the stomach (or any other organs) to move fully back into the abdomen and out of the chest cavity.
• Making sure that the lower part of the oesophagus is in the correct position once the stomach has moved back into place.
• Using stitches or sutures to repair the hole in the diaphragm.

A fundoplication may also be carried out. This is a technique that is used to treat instances of gastrointestinal reflux. There are different ways to do this with the most common being Nissen’s fundoplication.

Generally, the operation has two stages:

• The surgeon will check to see if the opening around the oesophagus is loose and requires intervention to tighten it.
• Part of the upper stomach is used to ‘wrap’ around the oesophagus and this is stitched together loosely. This should mean that the sphincter is tightened which reduces acid reflux but does not feel tight enough to affect swallowing.

It is important that no retching or vomiting happens post-surgery to repair your hiatal hernia as this could put undue stress on the stitches and lead to complications and bleeding. Anti-sickness medication may need to be prescribed until you are fully healed.

Many people with a hiatal hernia are able to control their condition, with some experiencing no symptoms at all. For those who experience complications as a result of their hiatal hernia, the prognosis following surgery is usually good.

When living with a hiatal hernia it is important to continue to follow any dietary and lifestyle changes that have been recommended to you, even if you start to feel better. You should always take any medication you need as directed and speak to your GP if your symptoms get worse or you have any concerns about your health.