hiatal hernia : What can you tell me about hiatal hernia?

Q: What can you tell me about hiatal hernia?

A: The diaphragm is a muscular sheet that separates the chest cavity (containing the heart, lungs, esophagus and other organs) from the abdominal cavity (containing the stomach, large and small intestine and other organs). A hiatal hernia refers to the abnormal passage of a portion of the stomach upward into the chest through a hiatus (opening) in the diaphragm.

The vast majority (about 90 percent) of hiatal hernias are of the so-called "sliding" type, in which a portion of the stomach passes upward into the chest through an opening that the esophagus normally passes through on its downward course to the stomach. A sliding hernia tends to move in and out of the thoracic cavity across the diaphragm, although the diaphragm itself is normal.

Sliding hernias are of particular importance because they are associated with gastroesophageal reflux (the passage of acid- containing stomach contents into the esophagus). This causes a burning sensation in the area of the heart and behind the breastbone (sternum), a feeling commonly referred to as "heartburn." However, not all persons with hiatal hernias have reflux; conversely, not all individuals with reflux have sliding hiatal hernias.

The key to treatment of hiatal hernia is to prevent the reflux of gastric acid contents into the esophagus. In most cases, this can be accomplished medically without the need for surgery.

Reflux of gastric contents into the esophagus is greatly enhanced by increased pressure within the abdomen. Consequently, tight belts, pants, corsets and pantyhose should be avoided; an obese patient is strongly encouraged to lose weight. It is important to avoid large meals, not lie down or bend over immediately after eating and refrain from eating for a few hours before bedtime. A person with symptomatic hiatal hernia should sleep with the head of the bed elevated four to six inches (using a wedge under the mattress), so that the force of gravity helps keep stomach acid away from the hernia.

It is best to avoid certain foods (dietary fat, chocolate, peppermint, acidic juices, carbonated beverages and caffeine) as well as tobacco and alcohol.

Antacids (taken in relation to meals and especially at bedtime) are usually quite effective in relieving the symptoms associated with reflux of gastric acid into the esophagus. Drugs that speed up emptying of the stomach or prevent reflux may also be of value.

Some persons with hiatal hernia and reflux have persistent or recurrent symptoms despite adequate medical therapy. In such cases, a surgical procedure may be necessary. The most popular of these is the Nissen fundoplication, in which the surgeon wraps the upper part of the stomach around the esophagus. A success rate of about 95 percent has been reported. Some minor complications such as difficulty swallowing or bloating usually improve over time in most people.

Virgil Williams and Ron Eisenberg are staff physicians at Highland General Hospital in Oakland. Please send questions to them in care of ANG, P.O. Box 10367, Pleasanton, CA 94588. Questions cannot be answered individually; however, some will be discussed in future columns.
Oakland Tribune, Jun 8, 2003
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