Hiatus Hernia

"Hiatal hernia occurs when the upper portion of the stomach moves up into the chest through a small opening that exists in the diaphragm (diaphragmatic hiatus)".

DR. RAMÓN ANGÓS MUSGO
SPECIALIST. DIGESTIVE DEPARTMENT

The diaphragm is the muscle that separates the chest from the abdomen. The diaphragmatic hiatus is part of the anatomical barrier that separates the esophagus from the stomach.

If the stomach is moved into the chest, this barrier is ineffective and gastric contents can easily pass into the esophagus. Therefore, the existence of a hiatus hernia favors gastro-esophageal reflux, but it is not its only cause.

Although it is more common after the age of 50, there are many otherwise healthy people of all ages who have hiatal hernia.

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What are the symptoms of hiatal hernia?

The burning ("pyrosis" in medical terms) that ascends from the stomach to the throat is the main symptom of GER. It may be associated with the passage of sour or bitter food from the stomach to the mouth.

It generally worsens after meals, especially with foods that favour the relaxation of the sphincter or with dietary excesses. In many cases also it worsens during the nocturnal rest or when the trunk is flexed.

In some cases the predominant symptoms are respiratory: aphonia or hawkish (by irritation of the larynx by the refluxed acid) or even asthma or respiratory difficulty (by aspiration of the acid to the airway).

What are the most common symptoms?

  • Burning or stinging.
  • Throat clearing.
  • Bronchial asthma.
  • Breathing difficulty.

Do you have any of these symptoms?

You may have a hiatal hernia

What are the causes of hiatus hernia?

The existence of a hiatus hernia "per se" does not require treatment unless the above-mentioned complications exist.

There are dietary factors or lifestyles that may contribute to gastro-esophageal reflux.

Chocolate, pepper or spices, mint, fats, coffee and alcoholic beverages promote the relaxation of LES and therefore, reflux. Tobacco also produces relaxation of the sphincter.

All those situations that involve an increase in intra-abdominal pressure (obesity, pregnancy, certain types of physical exercise) also favor GER.

What are the complications of hiatus hernia?

There are various complications derived from GER, although these do not occur in most cases. They depend on the severity of the reflux in each subject.

The most frequent is esophagitis, which is the inflammation of the esophageal mucosa exposed to acid. There are different degrees. Severe esophagitis can: ulcerate and bleed; heal irregularly, reducing the diameter of the esophageal light and making it difficult for food to pass through.

In some cases there may be a change in the normal esophageal mucosa, which is replaced by a mucosa more like that of the stomach or small intestine, more resistant to acid. This situation is known as "Barrett's esophagus" and its main importance is that it is considered a risk factor for developing esophageal cancer.

How is hiatal hernia diagnosed?

The initial diagnosis of hiatal hernia is based on the symptoms; however, if these are daily or it is necessary to maintain pharmacological treatment for more than 2-3 weeks, it is convenient to perform more specific explorations.

  • X-rays: a liquid is administered orally, which is opaque and can be seen by X-rays, and the passage from the esophagus to the stomach and the existence or not of reflux into the esophagus are studied.
  • Gastroscopy: a tube with a video camera at its tip is inserted through the mouth to reach the stomach. It allows the walls of the esophagus and the stomach to be seen directly, which makes it possible to know whether esophageal inflammation (esophagitis) has occurred and its severity; it also allows samples to be taken for biopsy in the event of finding lesions and to rule out other diseases that may simulate GER.
  • Esophageal manometry: a probe studies how the esophagus moves when the patient swallows liquids.
  • 24-hour pH metry: consists of inserting a probe through the nose with a system in the tip that detects the pH that exists in the esophagus and/or stomach. It allows us to know when reflux episodes occur, how long they last, whether or not they are related to the symptoms, etc.

How is a hiatal hernia treated?

Treatment of GER depends on its severity. In mild cases the objective is only to control the symptoms; in severe or complicated cases the objective of the treatment goes beyond clinical relief and aims to avoid or treat the complications derived from this reflux.

In any case, the first step is to take some simple dietary and postural measures that allow in many cases (25 percent) an adequate control of the symptoms:

  • Avoid foods and drinks that promote relaxation of LES, including fats (especially fried), pepper and spices, chocolate, alcohol, coffee, citrus fruits and tomatoes.
  • Lose weight in case of obesity.
  • Stop smoking.
  • Raise the head of the bed about 10 cm. It is important NOT to place pillows, which only manage to bend the neck. The aim is to achieve an inclination of the whole trunk, that is why we recommend articulated beds or placing wooden blocks on the front legs of the bed.
  • Avoid lying down until 2 or 3 hours after eating.
  • Pharmacological treatment is indicated when the above measures are not sufficient.
  • The dietary and postural measures MUST be maintained despite following a pharmacological treatment, since it has been demonstrated that they help sensitively to the good clinical control of the disease.

There are basically 2 types of pharmacological treatment:

Drugs that decrease acid secretions from the stomach.

  • Antacids: they manage to neutralize the acid existing in the stomach. They achieve rapid, albeit temporary, relief of symptoms. If they are required for more than three weeks in a row, it is essential to go to the doctor to study the possible reflux and opt for the most appropriate treatment.
  • Antisecretion: inhibits acid secretion from the stomach. The acid that exists at the time the symptoms occur is not neutralized, so the relief of symptoms is not as fast as that achieved by antacids, although it is more durable. It can be considered a way to "prevent" the symptoms, rather than eliminating them immediately once they appear. These are the drugs used in cases of chronic symptoms, when we speak of "gastro-esophageal reflux disease". There are many types of anti-secretory drugs, which differ in their ability to inhibit secretion.
  • Drugs that increase the muscle tone of the LES and promote emptying of the stomach.They are generally known as prokinetics. They are usually used in association with the above to achieve greater effectiveness.

Sometimes they may be the only maintenance treatment needed.

In principle, GER is a chronic disease, and as such, requires maintenance treatment, although this depends on the severity of the reflux and the existence of complications.

In general, mild and uncomplicated cases only require symptom control, and the duration of treatment depends only on the discomfort referred by the patient.

In serious or complicated cases, maintenance treatment is required even if there are no symptoms.

When a long-term pharmacological treatment is necessary, or in the case that very high doses of anti-secretory drugs are required, a surgical treatment, called funduplication, can be chosen, and which at present can be performed in most cases by laparoscopy (minimally invasive surgery).

A detailed study of the GER of each particular case is important before indicating the surgical treatment.

Where do we treat it?

IN NAVARRE AND MADRID

The Department of Digestive
of the Clínica Universidad de Navarra

The Digestive Department of the Clinica Universidad de Navarra is composed of a multidisciplinary team of specialists who are experts in the diagnosis and treatment of diseases of the digestive tract.

Our objective is that each diagnosis be carefully established and the treatment plan adjusted to each patient.

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Why at the Clinica?

  • Medical specialists who are national references.
  • Specialized nursing team.
  • Endoscopy Unit and High Risk Digestive Tumor Prevention and Consultation Unit to offer the best care to our patients.

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