HIATUS HERNIA

WHAT IS A HIATUS HERNIA?

A hiatus hernia is a type of internal hernia and does not appear as a lump like other types of abdominal wall hernia.

A hiatus hernia occurs when part of the stomach is pushed upwards through the opening in the diaphragm known as the hiatus and into the chest.

Most hiatus hernias are known as simple or sliding hernia where the junction between the oesophagus and stomach slides up into the chest. Far less common are hernias where part of the stomach also “rolls” up into the chest. This type of hernia may be associated with more serious complications such as strangulation.

WHAT CAUSES A HIATUS HERNIA?

Some babies are born with a hiatus hernia this is known as a congenital hernia and requires specialist paediatric surgical input. In most cases the exact cause of a hiatus hernia cannot be found. We know that hiatus hernias become more common as we get older. Other associated causes are associated with increased pressure on the muscle of the diaphragm. If this increased pressure is repeated a hiatus hernia may develop. Causes of increased abdominal pressure include:

  • being overweight
  • coughing
  • vomiting
  • straining to empty bowels
  • staining to pass urine
  • lifting heavy objects

Many people have a hiatus hernia without knowing and without it being a problem. A Hiatus hernia cannot be seen from the outside like other types of hernia. If a hiatus hernia is not causing any symptoms it doesn’t need any treatment.

Larger hiatus hernias may cause symptoms. The commonest symptom of a hiatus hernia is Gastro-Oesphageal Reflux Disease often abbreviated to GORD. This is often called acid reflux or heartburn. The symptoms occur when stomach contents such as acid and sometime food and gas escape upwards into the oesophagus, also known as the food-pipe or gullet.
Symptoms of gastro-oesophageal reflux (GORD):

  • burning feelings behind your breastbone often after eating (heartburn)
  • bring up small amounts of food or bitter-tasting fluids (acid reflux)
  • feeling or being sick
  • bad breath
  • burping and bloating
  • difficulty or pain when swallowing
  • night time cough
  • waking up with choking feeling

You should seek advice from your doctor if:

  • your symptoms don't go away after 3 weeks
  • your symptoms are very bad or getting worse
  • simple medicines from the chemist are not helping

You should seek urgent advice if you have indigestion / acid reflux and:

  • you have experienced weight loss
  • you are experiencing difficulty swallowing
  • you are being sick (vomiting)
  • you notice any blood in your sick (vomit)
  • you develop upper abdominal pain

Once a hiatus hernia has been diagnosed there are simple things you can do to improve symptoms of GORD:

  • Lose weight
  • Reduce alcohol intake
  • Stop smoking
  • Wear looser clothing
  • Avoid bending or lying over after eating
  • Raise bed head by 15cm
  • Avoid eating immediately before bedtime
  • Use medication to reduce acid
  • Use medication to help the stomach empty.

LIFE STYLE CHANGES

Changing your diet can reduce your symptoms. It may help to eat smaller meals several times a day instead of three large meals. Certain foods can increase the risk of heartburn.

Five types of food to avoid if you have heartburn:

  • spicy foods
  • chocolate
  • caffeine
  • onions
  • citrus fruits

Most people won’t need an operation for a hiatus hernia. Your doctor may decide to refer you to see a specialist if they want to confirm what is wrong or if your symptoms are bad and not improving with simple treatments.

When you see a specialist in the clinic we will take a full medical history including details of any previous illnesses, operations as well as your current medication. Based on this we will decide which further tests or investigations may be necessary. The following tests may be necessary particularly if surgery may be needed.

DIAGNOSIS

Endoscopy

An endoscopy is usually required to diagnose a hiatus hernia. This involves having a tube passed through your mouth and down into your oesophagus and stomach. It is useful to see if there is any inflammation being caused by reflux and important in ruling out any more serious problems that may be causing the symptoms.

Contrast X-ray

You may also need a contrast X-ray. This involves drinking a cup of contrast whilst X-rays are taken. This gives us a clear view of your oesophagus and can show if there is a hiatus hernia and can also be used to detect reflux.

Oesphageal manometry and PH studies

This test involves having a small tube passed through your nose and down the oesophagus. Using tiny sensors we can measure the pressures in the oesophagus and in particular at the junction between the oesophagus and the stomach. We can also measure whether there is acid in the oesophagus indicating reflux. As symptoms of reflux don’t occur all the time the probe can be left in place for 24 hours. This is known as ambulatory monitoring.

SURGERY FOR A HIATUS HERNIA

If simple medication and lifestyle changes are not working, if you have symptoms of reflux and a hiatus hernia and this is confirmed by tests, your surgeon may discuss an operation with you. Most surgery for hiatus hernia and reflux is done as a laparoscopic or keyhole operation. The operation is performed under a general anaesthetic and takes between 1 and 2 hours. The operation involves making a number of small cuts (incisions) in your abdomen. The commonest type of procedure performed is a wrap, also known as a fundoplication but there are other methods in use. The surgeon will reduce the size of the hole in your diaphragm using stiches to reduce the size of the hole your oesophagus passes through. The other part of the operation is to wrap the upper part of the stomach around the lower part of the oesophagus to create a new valve. The aim of the repair is to narrow the junction by just the right amount. If the narrowing is not enough then symptoms may come back, if the junction is made too tight then it may be difficult to swallow food.