Hiatus hernia

On second thought, I believe the hernia was higher up. This means it is a hiatus hernia. The one symptom I have that puts me at risk is that I am:
1) slightly overweight
2) suffering from indigestion

Published by BUPA's Health Information Team
August 2003

A hiatus hernia is when part of the stomach slides through the diaphragm, the muscular sheet that separates the lungs and chest from the abdomen.

A hiatus hernia often causes no symptoms, but can cause pain and heartburn. It is not usually a serious condition, and often needs no treatment. Any symptoms can usually be treated with drugs, or if severe, an operation.

About hiatus hernia

Normally, the stomach is completely below the diaphragm. The weakest part of the diaphragm is the hole through which the oesophagus (gullet) passes. A hiatus hernia forms when part of the stomach slides through this hole (hiatus) into the chest cavity.

There are two main types of hiatus hernia. With a sliding hiatus hernia, the ring of muscle (sphincter) that forms a valve between the oesophagus and stomach slides up through the diaphragm. This is the most common type of hiatus hernia. The other type, a rolling hiatus hernia, involves part of stomach bulging up through the hole in the diaphragm alongside the oesophagus.
What are the risk factors?

Doctors are not sure what causes hiatus hernia, but people are more likely to get it if they are:

* aged over 50
* smokers
* overweight
* pregnant

It may therefore be associated with conditions that increase pressure in the abdomen (eg smoker's cough and excess weight). It is also possible that the diaphragm muscle may weaken with age.

A rare form of hiatus hernia may be present at birth because the diaphragm or stomach have not developed properly.

Sliding hiatus hernia/Rolling hiatus hernia
Hiatus hernias
Symptoms

Often hiatus hernia has no symptoms. However, it may cause a feeling of warmth or burning in the chest, often called heartburn. This happens when the contents of the stomach, which are acid, flow backward (reflux) into the oesophagus. If heartburn symptoms are persistent or severe, this is called gastrooesophageal reflux disease (GORD).

Hiatus hernia can cause pain and discomfort behind the breastbone (sternum). If severe, this can feel similar to a heart attack.

Symptoms may occur or become worse after eating, soon after lying down or when bending forwards. They may be worse after drinking coffee or other hot drinks, or spicy food.

Hiatus hernia is just one of the possible causes for the symptoms described. These are common symptoms of indigestion. For more information, please see the separate BUPA factsheet Indigestion.

Complications

Occasionally, hiatus hernia can lead to more serious problems. Unlike the stomach, the lining of the oesophagus is not designed to withstand acid, so reflux of the acidic contents can damage the lower end of the oesophagus. This makes symptoms worse and can lead to the formation of ulcers (breaks in the lining of the oesophagus). If ulcers bleed there may be vomiting of blood. Anyone who experiences this needs urgent medical treatment to stop the bleeding, and should contact a doctor.

A bleeding ulcer can also lead to anaemia, where the body does not have enough red blood cells to transport oxygen around the body. For more information, please see the separate BUPA factsheet, Anaemia.

In the longer term, as ulcers heal they can result in a narrowing (stricture) of the oesophagus, which can cause difficult, painful swallowing and regurgitation of food.

There is also an increased risk of deveoping a condition called Barrett's oesophagus, where the cells lining the oesophagus undergo changes and become "pre-malignant", which means they have the potential to become cancerous. At this early stage, treatment can prevent cancer. However, people with GORD have a slightly increased risk of oesophageal cancer.

Diagnosis

Anyone who visits their doctor about indigestion symptoms will be asked further questions, and may sometimes be referred to a specialist doctor - called a gastroenterologist - for tests:

* X-ray - a hiatus hernia can be seen with X-rays taken after a drink containing barium, which shows up as white on the X-ray. The barium drink coats the lining of the oesophagus and stomach. This is called a barium swallow.
* Endoscopy - a hiatus hernia can be examined with a long, thin, flexible telescope called an endoscope, which is usually passed through the mouth and then swallowed. This instrument will also allow a close inspection of any ulcer at the lower end of the oesophagus. If necessary a sample of tissue (a biopsy) can be removed for a closer examination under a microscope.

Treatment of hiatus hernia
Self-help

A number of lifestyle changes may reduce the symptoms of hiatus hernia:

* eat small frequent meals rather than fewer large meals
* avoid bending over or lying down after a meal
* avoid foods that seem to cause more severe symptoms such as spicy foods, coffee and possibly alcohol
* stop smoking
* lose excess weight if overweight
* sleep propped up on plenty of pillows or with the head end of the bed raised 10 cm

Non-prescription medicines
Antacids

Antacids can be taken in either in liquid or tablet form. Those containing magnesium or aluminium generally work by neutralising the stomach acid. Others contain an ingredient called an alginate which forms a barrier that floats on the top of the stomach contents and prevents them splashing back up into the gullet, thus preventing heartburn and reflux symptoms. Another medicine that coats the stomach is called bismuth. Many of the antacids contain a mixture of ingredients. Examples of antacid brands include Rennies and Gaviscon.

H2 blockers

If antacids don't work, or if large quantities of antacid are needed to be effective, a pharmacist may recommend a more powerful medication. One type of more powerful drugs that can be bought at a pharmacy are H2 blockers (also known as H2 antagonists). They work by reducing the amount of acid produced by the stomach. Examples are famotidine (Pepcid Two) and ranitidine (Zantac).

Prescription-only medicines

Anyone who needs to take medicines for indigestion regularly, more than two or three times a week for example, should discuss their symptoms with a doctor. Doctors can prescribe longer-acting H2 antagonists. They can also prescribe another type of drug called a proton pump inhibitor, which also works by reducing acid production. Examples are omeprazole (Losec) and lansoprazole (Zoton).

Other medications work by coating the stomach lining, to protect it against the acid-attack. These include, sucralfate or carbenoxolone.

Complementary therapy

Some people find that the symptoms of a hiatus hernia can be improved by better postural balance which may be achieved with the Alexander technique. Some people find that other complementary treatments such as acupuncture, relaxation and visualisation, yoga and tai chi are also helpful, but it is not clear what effects they have and there is no scientific evidence to suggest they are effective.

Surgery

Rarely, a hiatus hernia causes such severe symptoms or complications that surgery is recommended. The operation is called a fundoplication. This involves making a cut in the upper abdomen, pushing the stomach back into the correct position and securing it there, and then repairing any gap of the diaphragm. The procedure can be done by open surgery (through an incision in the abdomen) or by keyhole (laparoscopic) surgery.
Further information

Digestive Disorders Foundation
Tel: 020 7486 0341
http://www.digestivedisorders.org.uk