What Is A Hiatal Hernia ? Hiatal hernia is the protrusion of the upper part of the stomach into the thoracic area through the hiatal opening in the diaphragm through which the esophagus passes into the abdominal area.

• The exact reason for this condition is unknown, but obesity, age, and smoking, are known to increase the risk of developing hiatal hernia.
• Hiatal hernia may be asymptomatic in most cases; but symptoms, when present, can vary from minor indigestion and esophageal reflux, to more troublesome cheat pain, difficulty in swallowing, belching and bloating.
• A barium swallow x-ray helps diagnose hiatal hernia.
• The symptoms due to hiatal hernia are treated by certain lifestyle changes and drug therapy. Occasionally surgery may be required to prevent dangerous complications.

Diaphragm is the thick muscular membrane between the thoracic (chest) cavity and the abdominal cavity. When any organ in the abdomen protrudes through the diaphragm, it is termed as diaphragmatic hernia. The esophagus passes from the thoracic cavity into the abdominal cavity through an opening in the diaphragm called esophageal hiatus. When a diaphragmatic hernia protrudes through the esophageal hiatus, it is known as hiatal hernia. The reason for the occurrence of this condition is not clear but it is prevalent in older people above the age of 50. It is more common in obese people, especially obese women, and in those who have the habit of smoking. Congenital defects and damage from injuries may be the cause of other forms of diaphragmatic hernia.

Hiatal hernias are of two types mainly:

• Sliding hiatal hernia - is a condition in which the upper part of the stomach, along with the junction of the esophagus and the stomach (gastroesophageal junction) slides up into the thoracic cavity through the esophageal hiatus.

• Paraesophageal hiatal hernia – occurs when the top most portion of the stomach protrudes into the thoracic cavity, to lie beside the esophagus, while the gastroesophageal junction remains in its normal position in the abdominal cavity.

Sliding hiatal hernia is a very common occurrence, with 40% people in the US having this condition. The frequency steadily increases with age so that among people above 60 years of age, the incidence is as high as 60%.

Symptoms

Sliding hiatal hernia does not usually cause any symptoms, especially if they are small. Minor symptoms which may occur are indigestion and gastroesophageal reflux. The symptoms are felt more often when people lie down after a meal or when the lean forward. Symptoms are worsened by activities such as lifting of heavy things and staining. During pregnancy also, people may have more severe symptoms.

Paraesophageal hiatal hernia has the potential of causing dangerous complications as it may get tightly pinched in the opening through which it protrudes, and the blood supply may get cut off. This dangerous condition is called strangulation, and it causes severe chest pain, difficulty in swallowing, bloating with gas, and belching. Strangulation is a medical emergency which requires immediate surgical intervention.

In both types of hiatal hernia there is a chance of the lining of the hernia bleeding, either slightly or massively, but it is not a very common occurrence.

Diagnosis and Treatment

An x-ray taken while slightly pressing down the abdomen can show the presence of hiatal hernia, but usually a barium swallow x-ray is done to get a better picture. The patient is given a radio opaque solution of barium to swallow prior to the x-ray so that the abnormalities in the digestive tract will be clearly shown in the image.

Sliding hiatal hernia may not need any medical treatment unless the symptoms such as gastroesophageal reflux are causing too much discomfort.  Certain simple lifestyle changes may reduce the acid reflux considerably. Instead of a few large meals, several small meals should be consumed. Quitting the habit of smoking usually helps, so does reducing weight.  People should avoid performing exercises or strenuous activities, as well as lying down, immediately after meals. Sleeping with the head in a higher position by raising the head of the bed, and wearing loose-fitting clothes also relieve reflux.

Dietary modifications which may help ease the discomfort due to this condition mainly involve avoiding foods which increase acidity. Acidic drinks such as colas and orange juice as well as other drinks like coffee and alcohol should be avoided. Food items to avoid include chocolate and onions in addition to all fatty foods. Avoiding acidic and spicy foods also helps. Drugs which inhibit the production of acids, and antacids which neutralize the acids produced by the stomach, help in reducing esophageal reflux.

Paraesophageal  hiatal hernia poses a high risk of strangulation and may have to be surgically corrected by laparoscopic procedure. It is a minimally invasive surgery involving a small cut in the abdomen or chest to insert the laparoscope through which doctors can see the affected area while doing the surgical correction. In some instances, open surgery may be necessary.

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