The esophagus is a tube that carries food from the mouth to the stomach. The diaphragm is the muscle that separates the chest from the abdomen.
- The esophagus goes through the diaphragm through a small opening called the hiatus.
- For a variety of reasons, part of the stomach can protrude up through the hiatus. When this happens, the result is a hiatal hernia.
There are two types of hiatal hernias: sliding hiatal hernia and paraesophageal hiatal hernia.
- A sliding hiatal hernia often goes undetected and may not be associated with any symptoms.
- A paraesophageal hernia is less common, but more likely to lead to complications.
One of the surgical procedures used to repair a hiatal hernia is called a Nissen fundoplication.
- During a Nissen fundoplication, the stomach is put back into its natural place. The hiatus tightened with sutures.
- The upper part of the stomach is then wrapped around the base of the esophagus. This is done to reduce the backflow of stomach contents into the esophagus (acid reflux).
A Nissen fundoplication can be done through an incision in the abdomen or chest, or through a laparoscope.
- A laparoscope is a thin, flexible tube with a camera and light on the end.
- When a laparoscope is used, the procedure is called a minimally invasive surgery.
- The surgical method is determined by the size of the hernia and surgeon's preference and experience.
Hiatal hernias can be related to increased pressure in the abdomen. Increased pressure can be caused by:
- Straining during a bowel movement
- Sudden physical exertion
- An inherited weakness in the muscular ring of the diaphragm (hiatus)
- Increased fluid in the abdomen
- Wearing tight clothing
- An injury to the abdomen
Although most hiatal hernias do not cause symptoms, some people experience:
- Difficulty swallowing with upper abdominal discomfort or fullness
- Chest pain
- Regurgitation and acid reflux (backflow of stomach contents into the esophagus)
If a hiatal hernia causes chronic acid reflux, you may develop other serious conditions. These can include:
- Inflammation and swelling of the esophagus
- Bleeding of the esophagus
- Pneumonia or asthma
- Obstruction, strangulation, perforation or hemorrhage if the hiatal hernia is severe
In addition, chronic exposure to stomach acid can cause the cells that line the esophagus to become more like the cells that line the stomach. This condition is called Barrett's esophagus.
- People who have Barrett's esophagus are at increased risk for developing cancer of the esophagus.
- Therefore, if you Barrett's esophagus you should be monitored for esophageal cancer.
If your hiatal hernia is not causing symptoms, no treatment may be needed.
- When symptoms are present, they can often be treated with medication and lifestyle changes.
- Be sure to follow your doctor's instructions for all over-the-counter (OTC) or prescription medications.
Lifestyle changes that may be recommended to ease your symptoms may include:
- Avoiding foods that may reduce the muscle tone of the lower part of the esophagus (i.e., chocolate, coffee, tea, cola, alcohol, peppermint, spearmint and fried or fatty foods)
- Avoiding foods that may irritate the lining of your esophagus (citrus fruits, tomato products, pepper and carbonated beverages)
- Eating smaller meals during the day and not eating for two to three hours before bedtime
- Eating slowly to reduce air swallowing and burping
- Losing excess weight to reduce the pressure on your stomach
- Avoiding vigorous exercise for two to three hours after you eat
- Avoiding tight clothing that puts pressure on your stomach
- Quitting smoking and use of other tobacco products
- Raising the head of your bed about six inches
- Avoid aspirin and non-steroidal anti-inflammatory drugs, such as ibuprofen, naproxen or aspirin
When you see your healthcare provider for evaluation, he or she will ask about your symptoms and perform a physical examination. Though your doctor may decide to treat your symptoms first, he or she may also order some tests. These tests can include:
- pH testing (to see how much stomach acid is in your esophagus)
- Esophageal manometric testing (to measure the difference in pressure between your stomach and your esophagus)
- An upper GI series (an x-ray of your esophagus, stomach and small intestine)
- An upper endoscopy (direct visualization of your esophagus through a small tube)
- Other imaging studies
Your healthcare provider may recommend surgery if:
- Your hernia is large
- Your stomach is in danger of strangulation
- The hernia causes symptoms that do not respond to usual treatment at home
If your healthcare provider recommends a hiatal hernia repair, prior to surgery tell him or her about any medications you are taking (including over-the-counter medications and supplements). Ask about specific instructions you should follow before surgery. These may include:
- Medications you should not take before the surgery, such as blood thinners or aspirin
- Regular medications you should continue to take on the day of your surgery
- How many hours you should stop eating and drinking before the surgery
If you are a smoker, you should quit smoking, as it can interfere with your recovery.
During your surgery, you will receive anesthesia to keep you comfortable and pain free.
- General anesthesia is the most common type of anesthesia for a hernia repair.
- With general anesthesia, you are put into a deep sleep. You will not be able to see, hear or feel anything.
After surgery your hospital stay and recovery period will depend on the type of surgery you had (laparoscopic or open).
- Pain medication and help at home may be needed while you recover.
- Do not forget to make arrangements for transportation to and from the facility.
What should I ask my healthcare provider before having a hernia repair?
- What do you think caused my hernia? How severe is it?
- Do I need any special tests? What are the benefits and risks of having the tests?
- Will the tests change your treatment recommendations? If not, is there a need for them?
- What are my treatment options? What are the benefits and risks of each treatment option?
- Besides surgery, are there less invasive treatment options for me?
- What minimally invasive procedures are available to treat my hiatal hernia? How many of these procedures have you done? What have the results been?
- Of the patients you have treated with either open surgery or minimally invasive surgery, how many of your patients have had their symptoms recur?
- Is there any other special preparation for the surgery? (If so, get clear instructions on what you need to do.)
- What kind of sedation or anesthesia will be used? What are the possible side effects?
- What are the possible complications to this surgery? How will I feel after the surgery?
- Will I have to modify my activities?
After your surgery, you should know what you had done, what medication was given and what symptoms you should report to your healthcare provider. You should also understand all home care instructions (including medications and side effects) and follow-up plans.