Hiatal hernia - Types, Symptoms, Diagnosis, and Treatment

Introduction

Hiatal hernia is a health condition where your stomach bulges and pushes itself up through the diaphragm muscle and reaches the chest.

There is an opening in the diaphragm called hiatus where the stomach pushes itself upwards to the chest, and so the condition is called hiatus or hiatal hernia.

The oesophagus passes through the small opening and then enters the stomach. When you have a hiatal hernia condition, the food tube and the stomach are pushed to the chest.

When there is a laxity in your hiatus, it might lead to other illnesses like GERD (gastroesophageal reflux disease). This laxity will cause the acidic content in stomach  to enter the oesophagus, which causes GERD symptoms like heartburn etc.

However, minor issues in the hiatal can be managed medically, but when the condition becomes large hiatal hernia requires surgery.

Hiatal hernia can be acquired or congenital. It can be commonly seen in elderly people. As we age, our muscle weakens, loses elasticity and becomes less flexible. So, this can be one of the reasons for the causes of hiatal hernia.

The other causes of hiatal hernia are chronic obstructive pulmonary disease (COPD), obesity, pregnancy, constipation, age, previous surgeries and other trauma.

Types of hiatal hernia

The four types of hiatal hernias are classified below.

• Type I
• Type II
• Type III
• Type IV

Sliding hiatal hernia

The sliding hernia or type I hernia is the most common, representing about 95%.

When you eat food, the food passes through the oesophagus which goes through the opening in diaphragm, to reach the stomach.

In sliding hernia, the stomach and the lower part of the hiatus are pushed towards the chest through the diaphragm.

The symptoms of sliding hernia are pain, heartburn, bloating, acidic taste in your mouth and difficulty swallowing.

Type II hernia

The type II hernia is also called as paraoesophageal hiatal hernia. The stomach will be pushed up towards the mediastinum in this type of hernia.

The mediastinum is a division of the thoracic cavity which contains many vital organs like the heart, trachea, blood vessels and thyroid glands.

Common symptoms of type II hernia are nausea, burping, chest pain, bloating and backflow of food.

Type III hernia

The type III hiatal hernia combines the paraoesophageal hernia and the sliding hernia.

The gastroesophageal and a small portion of the lower stomach are pushed towards the mediastinum.

According to data published in the journal Annals of Laparoscopic and Endoscopic Surgery, roughly 50% of patients with Type II-IV are asymptomatic.

Type IV hernia

When the stomach and other organs like the colon, spleen or small intestine are pushed towards the chest, type IV hiatal hernia is diagnosed.

The type IV hiatal hernia is called upside-down stomach and refers to the herniation of nearly the whole stomach.

The type III and type IV hiatal hernia is considered the rarest form of hernia. The recommended treatment for type IV hiatal hernia is thoracotomy, laparotomy or thoracolaparotomy.

Symptoms of Hiatal Hernia

The symptoms of hiatal hernia are briefed. However, these symptoms may vary from one person to another.

Heartburn

Heartburn is a common symptom of a hiatal hernia. Heartburn does not mean that your heart will burn. Heartburns are caused when the acid from the stomach comes up and irritates your oesophagus.

When the stomach has herniated towards the mediastinum, the acid from the stomach irritates the oesophagus, and the sensation of heartburn is felt.

Acid reflux or GERD

When the function of stomach is pushed towards the mediastinum, the stomach presses against the other supportive tissues.  

As a result, the other supportive tissues weaken and create abdominal pressure. This leads to GERD or acid reflux.

Chest pain

The hiatus can twist or squeeze the stomach. As a result, undue pressure is exerted on the stomach.

This causes the stomach to retain the acid, which flows to the oesophagus, creating chest pain and heartburn.

Trouble swallowing

Dysphagia or difficulty swallowing can be caused due to hiatal hernia. Dysphagia is a common symptom of sliding hernia.

The stomach will herniate towards the oesophagus and exert pressure on the food pipe. This causes difficulty in swallowing.

Belching

Belching or burping is a mechanism where your stomach expels out air from the upper digestive tract.

Burping is caused when you swallow excess air, one of the common symptoms of a hiatal hernia.

Causes of Hiatal Hernia

Being born with an unusually large hiatus

The hiatal hernia can be acquired or congenital. In rare cases, people born with large hiatus get affected by this hernia.

Injury

Trauma or injury to the diaphragm can cause a hiatal hernia. A sudden fall or a traumatic car accident can cause a hiatal hernia.

Obesity

Obesity can also contribute to hiatal hernia. Obesity can cause esophagitis. Esophagitis is the inflammation of the oesophagus.

The common cause of hiatal hernia is obesity. Hiatal hernia and esophagitis are interlinked.

Persistent and intense pressure

When persistent pressure is exerted on the surrounding muscles like the diaphragm and chest while coughing can lead to a hiatal hernia.

Treatments of Hiatal Hernia  

People affected with hiatal hernias are mostly asymptomatic, and treatments are available to treat hiatal hernias.

Medications  

Medications can treat symptoms like heartburn and burping. H2 blockers like cimetidine, famotidine and nizatidine are the common medication for hiatal hernias.

Proton pump inhibitors block the acid reflux and heal the severely damaged oesophagus.

Antacids are also prescribed to neutralise stomach acids. These antacids may bring quick relief. However, over usage of antacids can cause side effects like diarrhoea.

Surgery  

Surgery is usually preferred when medications do not help with the hiatal hernia. Symptoms like acid reflux and heartburn do not alleviate after medication use.

In such cases, surgery is preferred. Surgery helps pull the stomach down the abdomen and reconstruct the oesophageal sphincter. The preferred surgical methods are laparoscopy and thoracotomy.

In severe cases, hiatal surgery accompanied by weight loss surgery is also performed. It is called sleeve gastrectomy.  

Diagnosis of Hiatal Hernia

A hiatal hernia diagnosis is made after the symptoms like heartburn, abdominal pain and chest pain.

X-ray of your upper digestive system 

X-rays can be used to diagnose hiatal hernia. A thick liquid is given to swallow, which coats and lines the digestive tract.

This coating helps see the digestive tract and other organs clearly in an x-ray. And the doctor will diagnose your condition.

Upper endoscopy

Upper endoscopy involves inserting a small camera inside your stomach. The doctor will insert a small endoscope that contains a tiny camera at the end.

This device will help the doctor look for abnormal structures of the oesophagus, small intestine and duodenum.

Oesophageal manometry

Oesophageal manometry is used to test whether your oesophagus is working properly. It tests the number of contractions when you swallow, and the manometry measures the contractions.

The manometer also measures the force and the coordination of the oesophagus as the food moves through the pipe.

The oesophageal manometry is a thin, flexible tube passed through your nose. The catheter passes through the oesophagus and then to your stomach.

This test will help the doctor diagnose any damages to your oesophagus and other complications related to hiatal hernia.

Risk Factors of Hiatal Hernia

The cause of hiatal hernia is still not known. However, certain risk factors can lead to hiatal hernia.

Coughing

Sometimes the sudden pressure exerted in the oesophagus while coughing can cause a hiatal hernia.

Vomiting

A sudden flow of the liquid and the pressure exerted when you vomit can cause a hiatal hernia.

Straining during bowel movements

Straining during a bowel movement can cause a hiatal hernia. Constipation can also be a reason to cause straining during bowel movements. Consume fibre foods to relieve constipation naturally.

Lifting heavy objects

Pressure is exerted on the diaphragm while lifting heavy objects, and a hiatal hernia may be caused.

Lifting heavy objects for an extended time increases the risk of getting affected with a hiatal hernia.

Prevention of Hiatal Hernia

Hiatal hernia can be prevented by being consistent with certain small habits. Some of which are listed below.

Losing weight

Try to maintain a healthy BMI (body mass index). If you are obese or feel like you have put on some extra weight, cut down your calories.

Work out for at least an hour a day. Walking for 45 minutes daily will improve blood circulation and make you slightly calorie deficient.

Reducing meal and portion size

Reduce the portion size and eat frequent small meals. This will help to eat you less at the same time you will not feel hungry often.

Avoiding acidic foods, like citrus fruit and tomatoes

Limit the intake of citrus fruits and other acidic foods.

Avoiding caffeine and alcohol

Cut down your caffeine and alcohol intake. Social drinking may not cause such damage but limiting the consumption of alcohol is encouraged. Limits the caffeine drinks to two cups per day.

Avoiding peppermint

Limit the consumption of peppermint.

Limiting carbonated beverages

Carbonated drinks contain only sugar and feed you with empty calories. So, avoid consuming carbonated beverages.

Limiting fried and fatty foods

Fatty foods may be delicious when consumed, but they might not contain any good nutrient value.

Eating at least two hours before lying down

Make it a habit to eat early at night. Eat meals at least two hours before your bedtime.

When to see a doctor?

Most hiatal hernia patients are asymptomatic. However, consult your doctor when you have symptoms that are mentioned below.  

• Chest tightness, fever, irregular heartbeats, weakness and fatigue.
• If you have persistent chest pressure and trouble swallowing.
• If your stools have irregular and are black, maroon or bloody stools.
• If you vomit blood and it has the texture of coffee grounds, consult your doctor immediately.

However, these symptoms do not mean you might a have hiatal hernia. They might indicate other health conditions. Your doctor will diagnose fully and confirm the medical conditions.

Conclusion

Hiatal hernia symptoms can be managed by  medications, and in rare cases, surgery is preferred. A healthy lifestyle can prevent hiatal hernia.

Try to eat small healthy meals, limit the consumption of fried foods and always maintain a healthy weight.

Quit smoking immediately if you have the habit. These small changes can bring a big difference, and you can lead a healthy life.

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