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A hiatal hernia: what is it? Causes, Symptoms and Treatment

hiatal hernia causeshiatal hernia causesWe speak of hernia when an organ leaves part of the cavity which normally contains it, while passing through a natural orifice.

In the case of a hiatal hernia , it is the stomach that rises partly through a small opening called the “esophageal hiatus”, located in the diaphragm, the respiratory muscle that separates the thoracic cavity from the abdomen.

The hiatus normally allows the esophagus (tube that connects the mouth to the stomach) to cross the diaphragm to bring food to the stomach. If it widens, this hole can let go up part of the stomach or the entire stomach, or other organs contained in the abdomen.

There are two main types of hiatal hernia:

  • The hernia by sliding or Type I, which represents about 85 to 90% of cases.
    The upper part of the stomach, that is the junction between the esophagus and the stomach called “cardia”, goes up into the chest, causing burns related to gastroesophageal reflux.
  • The paraesophageal or rotating hernia or type II. The junction between the esophagus and the stomach remains in place below the diaphragm, but the larger part of the stomach “rolls” over it and passes through the esophageal hiatus, forming a sort of pocket. This hernia usually causes no symptoms, but can be serious in some cases.

 

There are also two other types of hiatal hernia, less common, which are in fact variants of the paraesophageal hernia:

  • Type III or mixed, when sliding hernia and paraesophageal hernia coincide.
  • Type IV, which corresponds to a hernia of the entire stomach sometimes accompanied by other viscera (intestine, spleen, colon, pancreas …).

Types II, III and IV together represent 10 to 15% of cases of hiatal hernia.

Who is affected?

According to the studies, 20 to 60% of adults would have hiatal hernia at some point in their lives. The frequency of hiatal hernias increases with age: they affect 10% of people under 40 and up to 70% of people over 60 years of age.

However, it is difficult to obtain a precise prevalence because many hiatal hernias are asymptomatic (do not cause symptoms) and are therefore not diagnosed.

Causes of the disease

The exact causes of hiatal hernia are not clearly identified.

In some cases, the hernia is congenital, that is, it is present from birth. It is then due to an anomaly of the hiatus which is too wide, or of the whole diaphragm which is badly closed.

However, the vast majority of these hernias occurs over the course of life and is more common in the elderly. The elasticity and rigidity of the diaphragm seem to diminish with age and the hiatus tends to widen, allowing the stomach to rise more easily. In addition, the structures that attach the cardia (the gastroesophageal junction) to the diaphragm, and that keep the stomach in place, also deteriorate with age.

Some risk factors, such as obesity or pregnancy, may also be associated with hiatus hernia.

Evolution and possible complications

The hiatal hernia by sliding mainly causes heartburn, but it is most often without gravity.

The hiatus hernia rotation is often asymptomatic but it tends to increase in volume over time. It can be associated with life-threatening complications, such as:

  • Respiratory difficulties, if the hernia is bulky.
  • Small continuous bleeding sometimes leading to anemia due to lack of iron.
  • A torsion of the stomach (gastric volvulus) which causes violent pains and sometimes necrosis ( death) of the part of the hernia torsion, deprived of oxygen. The wall of the stomach or esophagus can also tear, leading to gastrointestinal bleeding. It is then necessary to intervene urgently and to operate the patient, whose life may be in danger.

Symptoms of hiatal hernia

The symptoms differ according to the type of hiatal hernia . However, in many cases, the hernia does not cause any symptoms because it is not a disease in itself, just an organ in a bad position. It is sometimes diagnosed by chance, during a medical imaging examination such as an endoscopy or an X-ray.

Slip hiatus hernia

It can sometimes cause or aggravate gastroesophageal reflux (heartburn), that is, the rise of acidic juice from the stomach inside the esophagus.

The symptoms are:

  • Burning sensations that go up along the esophagus (acid reflux),
  • A bad taste in the mouth
  • Recurrent cough
  • Sore throat or hoarseness

Without treatment, acidic juices can eventually irritate the lining of the esophagus, causing oesophagitisand even ulcers (small wounds).

Note:
Some studies have shown that half of the people suffering from acid reflux at least once a week, and three-quarters of those with reflux esophagitis and a, had a hiatal hernia. However, these two entities are not synonymous: the hiatal hernia is not systematically associated with reflux, and conversely, the reflux is not always linked to a hiatal hernia.

Parasophageal hiatus hernia

It does not cause heartburn. Very often, it causes no symptoms or only intermittent discomfort.

When there are, the most common symptoms are:

  • Thoracic or gastric pain, such as stomach cramps
  • A feeling of heaviness and bloating after meals giving the impression of having eaten too much
  • Respiratory difficulty, shortness of breath caused by compression of the lungs by the stomach
  • Anemia caused by minimal but continuous bleeding

In rare cases, the poorly positioned stomach is twisted and may cause blood flow to the organ and cause tissue death. This causes severe pain, vomiting, and urgent surgery is required because severe gastrointestinal bleeding may occur.

People at risk for hiatal hernia

Hiatal hernia is more common in western countries and in people over 50 years of age. Women are also more prone to this type of problem than men, probably because of pressure in the abdomen during pregnancy.

Risk factors

Except for age, some factors seem to increase the risk of hiatal hernia:

  • overweight or obesity,
  • the pregnancy,
  • smoking,
  • Chronic cough, which increases the pressure in the abdomen.

The paraesophageal hiatal hernias are more common in people who have had surgery to reduce gastroesophageal reflux disease, or any other intervention involving the esophagus or stomach.

Prevention of hiatal hernia

Can we prevent?
To limit the risk of hiatal hernia , it is important to maintain a “healthy” weight, that is to say its weight of form. Nevertheless, it is impossible to definitively prevent the occurrence of a hernia.

In case of symptoms caused by a hiatal hernia, it is advisable:

  • Avoid wearing tight clothing at the waist or stomach, which can aggravate intra-abdominal pressure
  • Avoid staying leaning forward for too long (for example, during gardening)
  • To make small meals and avoid lying down just after eating
  • To limit the consumption of alcohol and tobacco
  • To avoid too acidic foods (tomatoes, citrus …)

See also our fact sheet on gastro-oesophageal reflux for more advice.

Medical treatments of hiatal hernia

Treatment depends on the severity of the symptoms and the type of hernia.

Slip hiatus hernia

Slipped hiatal hernias generally do not cause serious complications, but may be associated with gastroesophageal reflux.

The treatment is that of heartburn, several drugs that can be prescribed to limit gastric acidity or neutralize:

  • Antacids (Maalox, Gaviscon, Rennie, etc …) that neutralize the acidity,
  • H2-type antihistamines (cimetidine, Azantac, Pepcidac, etc …) that reduce the production of acid by the stomach.
  • Proton pump inhibitors (PPIs), prescribed if antacids or H2 blockers do not completely relieve symptoms (Mopral, Inipomp, omeprazole, esomeprazole, lansoprazole, etc.).

In case of persistent heartburn despite treatment, surgery to resorb the hernia and replace the stomach may be considered.

Hiatus rotation hernia (paraesophageal)

Important paraesophageal hiatal hernias or those causing troublesome symptoms should be surgically treated to avoid any potentially fatal complications, such as gastric volvulus. The procedure repositions the stomach under the diaphragm, while reducing the diameter of the hiatus and “tying” the stomach to prevent recurrence of the hernia.

The operation is effective and sustainable for the vast majority of people affected.

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