Hiatal Hernia

A hernia is a protrusion of part of an organ through the muscle wall that surrounds it. A hiatal hernia occurs when the upper part of the stomach pushes up into the chest through a small opening (called the hiatus) in the diaphragm, the muscle that separates the abdomen from the chest.

Most of the time, a hiatal hernia is small enough not to cause any symptoms and you may never know you have one. However, if your hiatal hernia is large enough, the opening in the diaphragm increases, allowing more of your stomach and sometimes other organs to slide into your chest. Sometimes, the hernia squeezes your stomach, causing restriction and discomfort. The stomach may rotate and twist as well. This results in retention of acid, which can easily back up into your esophagus, causing gastroesophageal reflux disease (GERD), heartburn, chest pain, swallowing problems, and breathing problems.

It is important that you choose an experienced medical team to treat your hernia. The Division of Thoracic Surgery at Brigham and Women’s Hospital (BWH) uses the most current diagnostic methods and offers proven treatments for patients with hernias, including minimally invasive laparoscopic surgical techniques aided by video technology.

Hiatal Hernia Topics

Types of Hiatal Hernias

Hernias are referred to by various names including hiatal hernia, paraesophageal hernia and the most rare, diaphragmatic hernia.

Hernias are also categorized by their size and configuration. The vast majority are called Type I, or sliding hiatal hernias. In this type of hernia, the stomach intermittently slides up into the chest through a small opening in the diaphragm.

Types II, III, and IV hernias are called paraesophageal hernias, which happen when a portion of the stomach pushes up into the chest adjacent to the esophagus. These hernias are much less common, but more concerning, because the blood supply to the stomach can be threatened and symptoms tend to be more severe.

Risk Factors for Hiatal Hernias

The cause of hernias is unknown. Men and women of all ages can develop a hernia, but possible triggers include the following:

  • Older than 50
  • Pregnancy
  • Obesity
  • Persistent pressure on the muscles of the hiatus caused by:
    • Coughing
    • Vomiting
    • Straining while having a bowel movement
    • Sudden physical exertion
    • Lifting heavy objects
Symptoms of Hiatal Hernias
Most of the time, a hernia does not cause symptoms but when it does they include:
  • Heartburn
  • Belching
  • Nausea
  • Vomiting
  • Regurgitation or backflow of stomach contents into the esophagus

More severe symptoms are usually associated with a paraesophageal hernia. Those signs and symptoms include:

  • Intermittent difficulty swallowing, especially solid foods
  • Feeling full after eating only a small amount of food
  • Abdominal or chest pain
  • Difficulty breathing after meals or increased shortness of breath
  • Voice changes
  • Abdominal bleeding, the signs of which can be:
    • Bright red blood in vomit
    • Dark red or black stools
    • Anemia
    • Blood test showing there is blood loss

Patients with paraesophageal hernias may have a significant portion of their stomach or other abdominal organs push up into their chest. In severe cases, the stomach or abdominal organs may rotate or twist, causing severe pain. This is a medical emergency and will likely require immediate surgery.

Diagnosis of Hernias
After a careful medical exam and taking your medical history, your board-certified thoracic surgeon may order one or more of the following tests to determine the cause of your symptoms:
  • Chest X-ray, electromagnetic energy produces images of internal tissues, bones and organs.
  • Chest CT-scan, a series of detailed pictures inside of the body, taken from different angles by a computer linked to an X-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly.
  • Upper Endoscopy (EGD), an endoscope is inserted through the mouth and into the esophagus allowing the surgeon to see the lining of the esophagus and remove a tissue sample (a biopsy), which is examined in a laboratory.
  • Barium Swallow/Upper GI study involves X-ray pictures of the esophagus and stomach after you have swallowed a small amount of contrast materialIf a patient complains of trouble swallowing, a barium swallow may be helpful in identifying areas of narrowing called strictures.
Treatment for Hernias
Hernias can often be monitored regularly. However, treatment may be necessary if the hernia is:
  • In danger of becoming strangulated (twisted in a way that cuts off blood supply to the stomach
  • Complicated by severe gastroesophageal reflux disease (GERD)
  • Complicated by esophagitis (inflammation of the esophagus)
  • Causing chronic anemia or a need for blood transfusions
  • Causing recurrent pneumonia or infection
  • Causing pain or inability to vomit
Treatments may include:
  • Medication to neutralize stomach acid, decrease stomach acid, or improve stomach motility.
  • Minimally Invasive Surgery
    • Laparoscopic surgery to reduce the size of the hernia or to prevent strangulation by closing the opening in the diaphragm. BWH thoracic surgeons perform laparoscopic operations by inserting a small video camera into the abdomen and viewing the procedure on a monitor, giving them better visualization and access. A fundoplication is performed in addition to reducing the hernia to help decrease acid and fluid from coming up from the stomach after the hernia is repaired. Fundoplication is usually performed as a laparoscopic procedure.
What You Should Expect

You will receive a thorough diagnostic evaluation and receive clinically proven treatment by a board-certified thoracic surgeon who specializes in hiatal hernias. Careful monitoring and the involvement of an experienced thoracic surgeon is important to the successful outcome for patients with hernias.

If you need surgery, you will be taken care of in the operating room by surgeons, anesthesiologists and nurses who specialize in surgery for patients with thoracic problems. After surgery you will go to the recovery room (Post Anesthesia Care Unit) and then you will be transferred to the Thoracic Intermediate Care Unit (TICU) where you will receive specialized comprehensive care by an experienced medical and nursing staff to get you better rapidly.


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