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Hernia, hiatus

 

A hernia happens when an internal part of the body, such as an organ, pushes through a weakness in the surrounding muscle or tissue wall.

A hiatus hernia occurs when part of your stomach pushes up into your chest (the stomach normally sits in your abdomen). It squeezes through an opening in the diaphragm, which is the large, thin sheet of muscle separating your chest from your abdomen.

The opening in your diaphragm is called the hiatus, and your oesophagus (the tube that carries food to your stomach) normally passes through this to reach your stomach.

What happens

At the base of the oesophagus is a ring-like muscle, called a sphincter, which closes the lower oesophagus. This muscle acts as a one-way valve, preventing stomach contents from flowing upwards into the oesophagus.

When part of your stomach pokes through the hiatus, it prevents the muscle from closing the lower end of the oesophagus.

A hiatus hernia can cause highly irritating stomach contents, such as acid, to move up into the oesophagus. This can cause heartburn and other problems, although in many cases a hiatus hernia causes no symptoms.

Antacid medicines can help to relieve symptoms.

Who is affected?

Hiatus hernia can affect anyone, but it is more common in women and people who are over 50, overweight, pregnant or who smoke. It is estimated that a third of people over 50 have a hiatus hernia.

There is a rare type of hiatus hernia that affects newborn babies.

 

Types of hiatus hernia

There are two types of hiatus hernia:

  • Sliding hiatus hernias are the most common. These are small hernias that slide up and down, in and out of the chest area. The sphincter (ring-like muscle) at the bottom of the oesophagus and top of the stomach pushes through the hole (hiatus) in the diaphragm.
  • Rolling hiatus hernias are less common. Part of the stomach pushes up through the hole in the diaphragm next to the oesophagus.

In many cases, a hiatus hernia causes no symptoms and is discovered by chance during a routine investigation.

If you have symptoms, they can include:

  • Severe heartburn.
  • Gastro-oesophageal reflux disease (GORD), where stomach acid flows back into the oesophagus (see Useful links).
  • Deep burning chest pain, which may affect the shoulder blades. The pain is made worse by bending forward, straining or lying down. The pain may disturb sleep and can be so severe that it is mistaken for angina or a heart attack.
  • Difficulty swallowing due to constant acid irritation.

Other symptoms can include a croaky voice and symptoms of asthma.

Glossary

Pain
Pain is an unpleasant physical or emotional feeling and your body's way of warning you it has been damaged.
Angina
Angina is chest pain caused by a reduced flow of blood to the heart, typically as a result of heart disease.
Stomach
The sac-like organ of the digestive system. It helps digest food by churning it and mixing it with acids to break it down into smaller pieces.
Heart attack
A heart attack happens when there is a blockage in one of the arteries in the heart.
Heartburn
Heartburn or indigestion is a painful, burning discomfort in the chest, usually after eating.

Preventing symptoms

Symptoms can be prevented or reduced by:

  • Eating frequent, small meals.
  • Avoiding foods that are hot, spicy, acidic or difficult to digest.
  • Losing weight, if you're overweight.
  • Avoiding tight-fitting clothes.
  • Elevating the head of the bed by four to six inches, to minimise acid regurgitation.
  • Stopping smoking.
  • Not drinking alcohol.
  • Avoiding eating or drinking late at night.

The exact cause of hiatus hernia is unknown, but it is more common in people who are:

  • over 50,
  • smokers
  • overweight or obese, or
  • pregnant.

Pressure on the abdomen

It is thought that excessive coughing, vomiting, straining or sudden physical exertion can be contributing factors of hiatus hernia as they create extreme pressure on the abdomen.

Obesity can also cause hiatus hernia because of the increased pressure on the abdomen.

Weakened diaphragm

It is estimated that one-third of people over 50 have a hiatus hernia, possibly because the diaphragm gets weaker with age, allowing part of the stomach to push through it.

Congenital problem

A rare type of hiatus hernia affects newborn babies. It occurs when the stomach or diaphragm does not develop properly.

A hiatus hernia may be diagnosed by:

  • Endoscopy. This is the most common test for hiatus hernia. An endoscope (a long, tube-like viewing instrument that contains a video camera and light source) is passed down the oesophagus (gullet) into the stomach.
  • X-ray. You will swallow a watery paste made from barium sulphate. It is a heavy, odourless powder that is insoluble (does not dissolve) and is not poisonous. It coats the inside of the stomach and makes it easier to see the digestive system when an X-ray is performed.

Both procedures allow the doctor to check for evidence of a hiatus hernia.

Glossary

X-ray
An X-ray is a painless way of producing pictures of inside the body using radiation.

If your hiatus hernia does not cause any symptoms, there is no need for treatment. If you have symptoms, antacid medicines and a change of lifestyle are the preferred treatments.

Treatment aims to prevent stomach acid from flowing back into the oesophagus, improve the clearance of food from the oesophagus and reduce the amount of stomach acid produced.

Antacid medicines

Antacid medicines can relieve some of the symptoms of hiatus hernia. Antacids come in liquid or tablet form and are swallowed or chewed. When they get to the oesophagus and stomach, they help neutralise the acid (make it less acidic).

Antacid medicines do not work for everyone. They are not a long-term solution if symptoms persist and cause extreme pain and discomfort. 

Alginates

Alginates contain a foaming agent, which forms a layer that floats on top of your stomach contents. This prevents stomach acid from flowing back into the oesophagus and protects your oesophagus lining. 

Acid-suppressing medicines

Acid-suppressing medicines reduce the amount of acid produced by your stomach. They are called histamine receptor blockers, or H2 antagonists, and include cimetidine, famotidine and ranitidine.  

Proton pump inhibitors

Proton pump inhibitors (PPIs) reduce the amount of acid produced by your stomach. They are usually the first treatment for gastro-oesophageal reflux disease (GORD), which can be a symptom of hiatus hernia.  

Motility stimulants

Motility stimulants, such as domperidone and metoclopramide, speed up the rate at which your stomach empties. They also improve the squeezing of the sphincter muscle, to help stop stomach contents being brought back up into your oesophagus. They can cause side effects, so only take them when needed.  

Surgery

Surgery may be an option in some cases of hiatus hernia if medication does not relieve your symptoms. Surgery may also be recommended for cases of GORD that do not respond to other treatments.

During surgery, the stomach is put back into the correct position and the diaphragm around the lower part of the oesophagus is tightened. Surgery is commonly performed using laparoscopy (the least invasive technique, where only a small incision is made in your abdomen). 

The operation is not complicated and most people go home the same day.

Ulceration and bleeding

Acid reflux (where stomach acid flows up into the oesophagus) may cause painful damage to the oesophagus lining and can cause ulcers and, in some cases, bleeding. Loss of blood can lead to anaemia.

Strangulation

In rare cases, the hiatus hernia can become strangulated (knotted). This causes its blood supply to be cut off and requires emergency surgery.

Stricture

Severe and long-lasting inflammation (swelling) can cause scarring and narrowing of the oesophagus. This may cause pain and can affect your ability to swallow food. This is called a stricture.

Barrett's oesophagus

Barrett's oesophagus is a rare condition that changes the cells of the lower oesophagus, increasing the risk of cancer of the oesophagus.

Cancer

There is a low risk of cancer of the oesophagus if you have long-term acid reflux.

Glossary

Acid reflux
Acid reflux is a condition that causes heartburn. It happens when acid from the stomach flows up into the throat.
Inflammation
Inflammation is the body's response to infection, irritation or injury. It causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.