Any time an internal body part protrudes into an area where it doesn’t typically belong, it is called a hernia. The hiatus is an opening in the diaphragm — the muscular wall that separates the chest cavity from the abdomen. Normally, the esophagus (tube of swallowing) passes from the neck, through the chest and then down through the hiatal passageway to the abdomen where the esophagus joins the stomach. A hiatal hernia is a protrusion of the stomach or other abdominal contents through the hiatus into the chest.
There are two main types of hiatal hernias: a sliding hernia and a paraesophageal hernia (next to the esophagus).
In a sliding hiatal hernia, the stomach and the portion of the esophagus that joins the stomach (gastroesophageal junction) slide up through the hiatus and into the chest. This is the most common type of hiatal hernia. Not all hiatal hernias cause symptoms. A paraesophageal hernia is less common, but can be more problematic. The esophagus and majority of the stomach stay in their normal locations, but a portion of the stomach squeezes through the hiatus and next to the esophagus. With a paraesophageal hernia, there is the possibility of the stomach twisting and possibly strangulating (twisting off its blood supply).
Many people with hiatal hernia have no symptoms, but others may have heartburn like symptoms that are related to gastroesophageal reflux disease, or GERD. GERD is caused by the backwash of gastric contents into the esophagus. This backwash causes sypmtoms of burning. Hiatal hernias are thought to predispose to GERD due to the abnormal location of a portion of the stomach in the chest. Although there appears to be a link between hiatal hernias and GERD, one condition does not necessarily mandate the other. Many people have a hiatal hernia without having GERD, and others have GERD without having a hiatal hernia. The symptoms of GERD can easily be mistaken for other disease processes. For example, people with heartburn may experience chest pain that can easily be confused with the pain of a heart attack. On the other hand, patients with a hiatal hernia may have symptoms attributed to it that are in fact related to another process. Therefore, it is critical to undergo thorough evaluation and testing before undergoing any surgery for a hiatal hernia or GERD. Your surgeon will help guide you in making this determination.
The cause of a hiatal hernia is not entirely known. A person may be born with a larger hiatal opening. Increased pressure in the abdomen such as from pregnancy, obesity, coughing, or straining during bowel movements may leading to stretching of the hiatus. Obesity may predispose to hiatal hernia and certainly worsens the symptoms of GERD.
Hiatal hernias occur more often in women, people who are overweight, and people older than 50.
A hiatal hernia can be diagnosed by chest x-ray, CAT scan or esophagram (a specialized form of x-ray study where a patient swallows barium contrast while x-rays are taken. Additionally, an endoscopy (telescope placed into the esophagus and stomach) may be used to diagnose a hiatal hernia.
Most people do not experience any symptoms from their hiatal hernia so no treatment is necessary. Patients with significant symptoms of heartburn should first be treated with antacid medications and modification of their eating habits to avoid foods that predispose to heartburn. If symptoms persist despite antacid therapy or if a patient has difficulty swallowing with food sticking (dysphagia), they should have their hiatal hernia repaired.