The insides of the belly are held in the abdominal cavity by the abdominal wall, for example. That is the wall affected by inguinal hernias.
The organs of the abdomen are also kept in place by the diaphragm. The diaphragm separates the abdominal cavity's organs from the heart and lungs in the chest cavity. It is a dome-shaped muscular layer between the two cavities.
The diaphragm is the part of the body that is affected by a hiatal or hiatus hernia. This muscle moves up and down for breathing. There are no open holes in the diaphragm, but key structures and vessels run through it.
The biggest one of these is the food pipe, named the esophagus. It runs down from the back of the mouth to the stomach, connecting the two, and is critical for pushing food down.
Just above the stomach, the diaphragm normally:
- Tightly surrounds the esophagus to keep abdominal organs and tissues in their place
- Stays attached to the esophagus when the food pipe narrows down after food passes through into the stomach
This narrowing down of the esophagus helps to keep the contents of the stomach from coming back up the chest part of the food pipe.
A hiatal hernia is where part of the upper stomach pushes through the diaphragm at this usually snug point. Part of the stomach can "herniate" at this "hiatus" if the opening is weakened.
Causes and risk factors for a hiatal hernia
Experts do not fully understand all of the causes of the weaknesses that result in hiatal hernias.
A hiatal hernia is thought to be caused by pressure pushing up on the diaphragm. There may be inherited genetic factors that make some people more at risk from pressure.
Experts believe that hiatal hernias are caused by pressure pushing up on the diaphragm.
The weakening has been linked to a number of risk factors that make it more likely. Hiatal hernias are more common among people:
- Over 50 years of age
- With obesity
Other risk factors include upward strain because of weightlifting. Even straining to push out a stool when emptying the bowel can be a factor. So too can persistent coughing or vomiting. These temporarily increase the pressure inside the abdominal cavity.
A hiatal hernia is seen more often in pregnant women. The abdominal organs are simply pushed upward during pregnancy. This sometimes causes the bulging through the diaphragm at the esophagus.
A defect in the diaphragm present at birth is another cause, but these hiatal hernias are rare.
Injury affecting the diaphragm can also lead to a hiatal hernia, such as trauma from falls or traffic accidents. Some food pipe surgeries carry the risk of one developing. This risk ought to be far outweighed by the benefits whenever a surgery is needed, however.
Symptoms of a hiatal hernia
The stomach bulging up as a hiatal hernia often gives no symptoms. It is often detected only by chance in people who have a scan for another reason.
These hernias are split into two broad forms:
The symptoms of a hiatal hernia are caused by acid coming up from the stomach.
- Sliding hiatal hernias are the most common and usually small. These hernias move up and down, rather than having a stomach portion that remains fixed and bulged out of place
- Fixed or rolling hiatal hernias are less common. About 1 in 10 hiatal hernias remain out of place, pushed up through the diaphragm
Both types are often without symptoms. The symptoms that are caused by hiatal hernias are the result of acid going up from the stomach.
Acid going up from the stomach can cause heartburn - a burning sensation around the lower chest area. Heartburn tends to worsen in relation to different foods and drinks or happens when lying down and bending over, especially when done soon after eating. It can produce a bad taste in the back of the throat, as well as bloating and belching.
If the heartburn symptom in particular becomes a regular problem, people have acid reflux. Acid reflux is a condition when heartburn keeps on happening at least twice a week.
If acid reflux happens too regularly for too long, this can progress to gastroesophageal reflux disease (GERD).
The heartburn, acid reflux, and GERD's relationship to a hernia, though, is that:
- Most hiatal hernias do not produce heartburn symptoms and problems
- Problems with acid going back up the food pipe are often because of something different to a hiatal hernia
Prevention and treatment of a hiatal hernia
The risk of a hiatal hernia related to obesity means that tackling obesity could prevent it, or at least help with controlling symptoms. Other known causes and risk factors are not preventable. In all cases when there are symptoms, these can be managed.
For any hiatal hernia, changes to eating and drinking can help. Dietary tips to help against hiatal hernias producing heartburn symptoms include:
- Reducing total meal sizes
- Reducing portions
- Not having so many of the foods that trigger more acid to be pushed up
Eating less chocolate could help against heartburn symptoms.
Items that may need reducing include:
- Acidic foods and drinks
- Fatty or spicy foods
The timing of eating and drinking can be a factor because mealtimes affect when acid can flow back into the esophagus.
People should have meals 3 hours of more before lying down to bed. They should also sit up while eating.
The British National Health Service add another tip. Real problems with acid might be helped by raising the head end of the mattress so that the bed slopes slightly toward the feet. If this is worth trying, they state, raise the whole body length of the bed into a slope. Using only pillows to raise just the head could put pressure on the abdomen and make acid problems worse.
If a hiatal hernia is causing enough of a problem with acid reflux, doctors may prescribe a drug to reduce stomach acid and heartburn symptoms.
Treatments to relieve symptoms are also available over the counter without prescription:
- Antacids are liquids or chewy tablets that reduce the acidity of the stomach contents
- Alginate products make a foamy gel at the top of the stomach contents, providing a barrier to acidic contents
Doctors can prescribe stronger medications for persistent problems.
Only rarely do hiatal hernias need surgery in hospital under general anesthesia:
- People who develop long-term, severe reflux problems may consider an operation if lifestyle and medical treatments do not work
- If part of the stomach squeezes through the diaphragm into such a bulge that it loses healthy blood supply, surgery becomes important
The operations for hiatal hernias are done through a large open incision or a few keyhole cuts. As with any general surgery, there are downsides, but these should be outweighed by the upside of treatment of a serious problem.
One of the operations guided by laparoscope through keyholes produces up to 90 percent improvement, according to the Cleveland Clinic.
The procedure, called laparoscopic Nissen fundoplication (LNF) is one of the most regularly performed to treat sliding hiatal hernias.
The operation lasts up to 1.5 hours to:
- Pull the stomach back down
- Tighten the diaphragm around the esophagus to stop the hernia bulge