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Hiatal Hernia 

Introduction

A hiatal hernia occurs when part of the stomach protrudes through the diaphragm, the muscle inside of the chest wall.  A hiatal hernia may cause no symptoms.  However, symptoms can occur from the back up of stomach acids, air, or bile into the esophagus due to the hiatal hernia.  This can cause heartburn, chest pain, swallowing difficulties, and belching.

A hiatal hernia is a common condition that can be prevented.  It is treated with lifestyle changes and medications.  Surgery is rarely needed.

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Anatomy
When you eat, your tongue moves chewed food to the back of your throat.  When you swallow, the food moves into the opening of the esophagus.  Your esophagus is a tube that rapidly moves food from your throat to your stomach.  The esophagus passes through the esophageal hiatus and then connects to the stomach.  The esophageal hiatus is an opening in the diaphragm.  Your diaphragm is a large muscle that separates your abdomen from your chest used to expand the lungs when you take a breath.
 
A ring of muscles, called the lower esophageal sphincter (LES), is located at the bottom of the esophagus.  The LES relaxes to allow food to enter the stomach.  The LES closes tightly after the food enters.  This prevents stomach contents and acids from re-entering the esophagus.  
The stomach produces acids to break down food for digestion.  The stomach also secretes mucus to protect the lining of the stomach from the acids.  The esophagus does not secrete mucus and is not protected from stomach acids. 

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Causes
The cause of a hiatal hernia is unknown.  It appears to be associated with weak supporting tissue, poor posture, smoking, obesity, and increasing age, especially over the age of 50.  Some infants are born with the condition.
 
There are three main types of hiatal hernia.  A sliding hiatal hernia is the most common type.  It occurs when the union between the esophagus and the stomach, including the LES, slides upward and through the esophageal hiatus in the diaphragm.  It becomes positioned above the diaphragm and in the chest cavity.  A sliding hiatal hernia results from increased pressure in the abdomen.  It resolves when the pressure is relieved.  A paraesophageal or fixed hiatal hernia results when a portion of the stomach moves up and remains in the chest cavity.  The third type of hiatal hernia is a mixed condition including both sliding and fixed features.

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Symptoms

A hiatal hernia in itself may cause no symptoms.  Symptoms may occur when stomach acids, air, or bile back up into the esophagus causing chest pain, pressure, and burning.  You may especially feel symptoms after eating, when lying down, or bending forward.  You may experience belching, coughing, hiccupping, and difficulty swallowing.

In rare cases, a strangulated hernia occurs when the blood supply is cut off from the trapped portion of the stomach.  A strangulated hernia causes excruciating pain and serious illness.  A strangulated hernia is an emergency medical condition, and you should seek immediate treatment in the emergency room of a hospital. 

A hiatal hernia may occur along with Gastroesophageal Reflux Disease (GERD).  GERD results when stomach contents and stomach acids re-enter the esophagus.  Normally, the LES closes tightly after food has entered the stomach.  With GERD, the ring does not close tightly.  Instead, it remains partially open allowing stomach contents and acids to pass back into the esophagus, damaging the lining.  The main symptom of GERD is heartburn.

A hiatal hernia or GERD can cause chest pain with heartburn.  The pain may feel dull and heavy in your chest.  Heartburn does not involve your heart in any way.  The condition was named “heartburn” because the area of discomfort is located near the heart.  However, the chest pain with heartburn can be confused with the chest pain associated with a heart attack.  You should call emergency services, usually 911, if you suspect you are having a heart attack.  Symptoms of a heart attack include chest pain that is crushing or squeezing, or a feeling like a heavy weight is on your chest.  These symptoms may occur with sweating, shortness of breath, nausea or vomiting, dizziness, lightheadedness, and pain that spreads from the chest to the neck or jaw.

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Diagnosis
Your doctor can start to diagnose hiatal hernia after reviewing your medical history and conducting a physical examination.  You should tell your doctor about your symptoms, including what makes your symptoms better or worse.  Your doctor may conduct tests to help confirm the diagnoses and rule out other diseases with similar symptoms.  Common tests include a barium swallow and an upper gastrointestinal (GI) endoscopy.
 
A barium swallow, also called an upper gastrointestinal (GI) series, provides a set of X-rays showing the esophagus, stomach, and small intestine.  Before the X-rays are taken, barium, a chalky substance, is swallowed.  The barium provides an image of the upper gastrointestinal structures on the X-ray images.  A barium swallow is commonly used to determine the cause of pain, swallowing problems, blood stained vomit, and unexplained weight loss.  A barium swallow is an outpatient procedure that does not require sedation or anesthesia.
 
An upper (GI) endoscopy is a procedure that uses an endoscope to view the esophagus, stomach, and upper duodenum, the first part of the small intestine.  This test is also called an esophagogastroduodenoscopy (EGD) or a gastroscopy. An endoscope is a long thin tube with a light and a viewing instrument that sends images to monitor.  The endoscope allows a doctor to examine the inside of the upper gastrointestinal tract for bleeding, ulcers or erosions, tumors, and other abnormal conditions.  A tissue sample or biopsy can be taken with the endoscope.  It is also used to treat bleeding.  An upper GI endoscopy is an outpatient procedure.  You will receive a medication to relax you prior to the test.

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Treatment
Hiatal hernia is treated with lifestyle changes, medications, and rarely surgery.  It is helpful to maintain an appropriate weight, stop smoking, improve your posture, and minimize bending or heavy lifting activities.  It is helpful to stand after eating and sleep with your head and chest elevated.  You should eat several small meals throughout the day instead of three large meals.  You should also eat your last meal two to three hours before bedtime.  Diet modifications include avoiding caffeine, chocolate, peppermint, alcohol, fried foods, and high-fat foods. 
 
Prescription and non-prescription antacid medications may minimize the symptoms of hiatal hernia.  Medications and lifestyle changes are often very effective.  In rare cases, surgery is needed to fix the structural abnormalities associated with this condition.
 
Hiatal hernia repair surgery is also called anti-reflux surgery or fundoplication.  It is used to correct a defect in the diaphragm.  The surgery may be performed with open surgery or laparoscopic "keyhole" or "endoscopic" surgery.  A laparoscope is a thin tube with a miniature viewing instrument.  It is inserted through small incisions.  Laparoscopic surgery uses smaller incisions than open surgery and is associated with less pain, less scarring, and a shorter hospital stay.  Another procedure, endoluminal fundoplication uses an endoscope to place small clips on the inside of the esophagus to help prevent reflux.

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Prevention
There are lifestyle changes you can make to prevent hiatal hernia or reduce its symptoms.  It is helpful to maintain an appropriate weight, stop smoking, improve your posture, and minimize bending or heavy lifting activities.  It is helpful to stand after eating and sleep with your head and chest elevated.  Eat several small meals throughout the day instead of three large meals.  You should eat your last meal two to three hours before bedtime.  Avoid consuming caffeine, chocolate, peppermint, alcohol, fried foods, and high-fat foods.
 
If you experience GERD, talk to your doctor about various treatment options.

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Am I at Risk
Because the specific cause of hiatal hernia is unknown, specific risk factors are difficult to identify.  However, factors that appear to contribute to the condition include obesity, poor posture, smoking, increasing age, frequently bending over, and heavy lifting.  Some infants are born with the condition.

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Complications
In rare cases, a strangulated hernia can occur when the blood supply is cut off from the trapped portion of the stomach.  A strangulated hernia causes excruciating pain and serious illness.  A strangulated hernia is an emergency medical condition and you should seek immediate treatment in the emergency room of a hospital. 
 
A hiatal hernia may occur along with Gastroesophageal Reflux Disease (GERD).  Untreated GERD can lead to damage of esophagus and bleeding.  People with GERD have an increased risk for developing esophageal cancer.  If you experience GERD, you should talk to your doctor about a screening schedule for cancer.

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This information is intended for educational and informational purposes only. It should not be used in place of an individual consultation or examination or replace the advice of your health care professional and should not be relied upon to determine diagnosis or course of treatment.

The iHealthSpot patient education library was written collaboratively by the iHealthSpot editorial team which includes Senior Medical Authors Dr. Mary Car-Blanchard, OTD/OTR/L and Valerie K. Clark, and the following editorial advisors: Steve Meadows, MD, Ernie F. Soto, DDS, Ronald J. Glatzer, MD, Jonathan Rosenberg, MD, Christopher M. Nolte, MD, David Applebaum, MD, Jonathan M. Tarrash, MD, and Paula Soto, RN/BSN. This content complies with the HONcode standard for trustworthy health information. The library commenced development on September 1, 2005 with the latest update/addition on April 13th, 2016. For information on iHealthSpot’s other services including medical website design, visit www.iHealthSpot.com.