Hiatal Hernia: what it is, causes, symptoms and treatments

• A hiatal hernia is the ascension of the stomach through the hole in the diaphragm known as the hiatus.
• In mild cases of hiatal hernia and gastro-oesophageal reflux, conservative treatment is the treatment of choice.
• When conservative treatment fails to relieve the hiatal hernia and its symptoms, the most recommended option is a hiatal hernia operation by laparoscopy.

To understand hiatal hernia, the hiatus is a hole in the muscle that separates the chest from the abdomen, called the diaphragm, through which the oesophagus passes, connecting the mouth to the stomach.

In the case of hiatal hernia, it occurs mainly when due to a series of factors, which we explain in the following section, the hiatus increases in size and dilates, making it easier for the stomach to ascend through it towards the diaphragm. This problem is known as hiatal hernia.

In many cases, this can be remedied in the early stages with lifestyle changes, medication or other conservative treatment, while in the case of a hiatal hernia that is too large or causes the severe symptoms mentioned below, the best option is to have a hiatal hernia operation performed laparoscopically.

One of the main problems of hiatal hernia is Gastroesophageal Reflux, and in many cases hiatal hernia surgery is considered to be anti-reflux surgery. Gastro-oesophageal reflux is a chronic problem that can cause very serious problems if left untreated.

Although there is nothing concrete and exact that can be considered a direct cause of the appearance of a hiatal hernia, we can comment on 3 factors that favour its formation. These are:

• Obesity: In patients who are significantly overweight, there is usually excessive pressure on the diaphragm, favouring the enlargement and dilatation of the hiatus.
• Age: With age, all the structures of the human body tend to weaken, especially if the patient does not lead an active life, does not eat a balanced diet, etc., which means that the area of the diaphragm where the hiatus is located weakens and becomes enlarged, causing the hiatal hernia we are talking about in this article.
• Tobacco and alcohol consumption: As we all know, smoking and drinking are not healthy habits, and in this case both are harmful both as factors in the onset and aggravation of symptoms. The acidity of alcohol and the circulation problems caused by tobacco help in the appearance of Gastroesophageal Reflux and hiatal hernia.

However, it does not imply that a person who smokes, is overweight and elderly will suffer a hiatal hernia or the opposite, but they are relevant factors in its appearance.

Problems arise when symptoms appear, the main and most serious of which are related to gastro-oesophageal reflux.

Firstly, hiatal hernia can be asymptomatic, although if someone is reading this article it is because they or a family member has symptoms and knows they have a hiatal hernia. Most commonly, the patient suffers from symptoms associated with Gastroesophageal Reflux, a pathology that goes hand in hand with hiatal hernia.

All this favours the appearance of the following symptoms, with oesophagitis being the most serious and the one that can cause the most complications for the patient:

• Heartburn: It is felt in the chest and goes up the throat. Increases when the patient is lying down or bending over.
• Ascension of food into the mouth: Regurgitations.
• Vomiting: May include blood if oesophagitis is present in addition to reflux.
• Aspiration pneumonias: If food passes into the respiratory tract.
• Throat irritation: mainly due to acid coming up the throat.
• Dysphonia, hoarseness and nocturnal cough: mainly caused by reflux problems.
• Dysphagia and alteration of the oesophagus: This occurs in the most severe and advanced cases, and the passage of food through the oesophagus to the stomach may be impeded.

Drinking alcohol and smoking do not help to improve these symptoms, but aggravate them.

When these symptoms appear, it is possible to diagnose hiatal hernia in a consultation with a specialist, either a primary care physician or a General and Digestive Surgeon, depending on each case, conservative treatment or surgical treatment may be chosen.

In order to define the treatment, it may be necessary to carry out a series of diagnostic tests, or at least some, to determine the severity of the Gastroesophageal Reflux or the hiatal hernia itself.

In addition to a face-to-face consultation in which the symptoms are perceived and the medical problem is defined, there are a series of tests associated with hiatal hernia that are performed, mainly to study the Gastroesophageal Reflux (GER), a major problem of hiatal hernia. 

These tests are:

• X-rays: Performed with contrast liquid to see how the liquid passes through the oesophagus and whether or not there is reflux when it reaches the stomach area. All this is possible because the liquid is opaque and can be seen through X-rays.
• Gastroscopy: This is the most commonly used for diagnosis. With the patient sedated, a flexible tube is introduced through the mouth until it reaches the stomach, allowing the walls of the oesophagus and stomach to be seen and to see if oesophagitis is present, as well as the possibility of performing a tissue biopsy to rule out other pathologies that may resemble GOR.
• Oesophageal manometry: This allows the oesophageal movements to be studied during the patient's liquid intake by means of a probe.
• Ph metry: This is a system that allows the ph of the oesophagus and stomach to be detected, as well as the different reflux episodes, their duration, their relationship with symptoms, etc.

The treatment of hiatal hernia and gastro-oesophageal reflux depends on the severity, but in mild cases the aim is to control the symptoms, at which point conservative treatment is chosen, which can be divided into pharmacological and habit-forming treatment:

Change in lifestyle habits

• Avoid foods that promote relaxation of the lower oesophageal sphincter: fats and fried foods, pepper and spices, alcohol, coffee, chocolate, oranges, lemons and other citrus fruits, as well as tomatoes.
• In cases where the patient is obese, weight loss is vital to reduce the pressure on the diagram.
• Smoking cessation: This is always complicated, but always beneficial.
• Raise the head of the bed: Recommended up to 10 centimetres, it is important not to do this by placing cushions or pillows as they can cause pain in the neck. It is better to raise the front legs of the bed directly or get an articulated bed.
• Do not lie down or sleep until 2 or 3 hours after eating. This is very important.

If symptoms persist, pharmacological treatment should be added, while maintaining these dietary and postural hygiene tips.

Pharmacological treatment

This type of treatment has two clear objectives: firstly, to reduce acid secretions from the stomach by taking antacids or antisecretory drugs; and secondly, drugs that increase the muscle tone of the lower oesophageal sphincter and favour stomach emptying.

All these medications must always be prescribed and supervised by a doctor, never self-medicate.

Finally, in cases where conservative treatment does not help the patient to alleviate symptoms and improve quality of life, a hiatal hernia operation by laparoscopy is an option.

The option of performing hiatal hernia surgery, which is usually done laparoscopically, a type of minimally invasive surgery, is usually taken in the following cases:

• Prolonged conservative medical treatment: If the patient has been undergoing treatment for a long time, he or she may decide to undergo surgery to solve the problem definitively.
• If the problems persist with medical treatment: If the patient continues to suffer from the same symptoms despite treatment, surgery is the best option to improve their quality of life.
• If after stopping treatment, symptoms return: If after a long time on treatment, you stop taking it and symptoms persist, surgery is a viable option.
• If the hiatal hernia is gigantic or excessively large: In these cases, surgery is the best option.
• If the patient suffers from severe oesophagitis: In this case, surgery is undoubtedly the best option.

When the patient has decided together with the General and Digestive System Surgery Specialist to carry out the hiatal hernia operation, the first thing to be done is a complete preoperative examination, in which a complete blood test is carried out, to check for signs of infection, an electrocardiogram, which allows the patient's heart health to be checked, as well as a chest x-ray if the doctor so indicates.

Once the preoperative and anaesthesia consultation has been carried out to define the anaesthesia to be used in the operation and all the necessary procedures have been completed, the patient is admitted and the hiatal hernia surgery is performed on the indicated day:

• On arrival at the hospital, the patient is given all the necessary documentation for admission, and is accompanied to a waiting room where he/she will wait a few minutes until called to enter the operating theatre.
• Before entering the operating theatre, the patient will be given sterile clothes for the operating theatre, an IV will be placed in the arm to administer the necessary anaesthesia and medication and then he/she will enter the operating theatre, where he/she will meet the specialist, the instrumentalist, the anaesthesiologist and members of the nursing team.
• In the operating theatre, the patient will be positioned on the stretcher as indicated by the surgeon, after which the anaesthesia will be administered and the surgery will begin as soon as it takes effect.
• First of all, the surgeon will disinfect the abdominal area where he will make the 3 or 5 mini incisions necessary to treat the hiatal hernia.
• He/she then introduces a harmless gas into the cavity to enlarge it and improve visibility.
• The next step is to insert the laparoscope into the area through one of these incisions. The laparoscope is an instrument that allows the inside of the body to be viewed on a monitor and the operation to be carried out without having to open the patient.
• The surgical tools needed to perform the hiatal hernia repair are then inserted.
• Once inside, the surgeon repairs the hiatal hernia by suturing the opening of the diaphragm to prevent the stomach from rising upwards. In addition, if there is gastric reflux, which is most common, an anti-reflux technique is performed to prevent reflux and the stomach from rising through the hiatus.
• This is a common surgery but requires a very refined technique.
• After solving the problem, the surgeon will check that the surrounding structures have not been damaged and will remove the gas, the laparoscope and the instruments and then suture the patient.
• Once the surgery is completed, the patient is awakened in the same operating theatre.

The duration of the laparoscopic hiatal hernia operation is approximately 1 to 2 hours. Afterwards, the patient spends 1 day in the hospital and can go home.

If you have a hiatal hernia and you are thinking of having surgery with us, remember that you can request a free surgical assessment consultation with our specialist in general surgery and the Digestive System, to get to know the doctor and decide on the best option to eliminate the symptoms of hiatal hernia once and for all. 

You can request the free surgical assessment consultation by clicking below: