Hiatal Hernia

Dr. Terry Murphy

ED Medical Director

Samaritan Hospital

A hiatal hernia is an abnormality in which a portion of the esophagus or stomach protrudes from inside the abdomen, through an opening in the diaphragm muscles, up into the chest.  The esophagus is a tubular structure that extends from the back of the throat through the central portion of the chest, down through an opening in the diaphragm muscles that separate the chest from the abdomen, and attaches to the stomach in the abdomen. The inner layer of the esophagus, the mucosa, is a smooth thin layer that produces a small amount of mucous to help swallowed food be propelled down the esophagus into the stomach with less friction during swallowing. These cells of the inner lining are sensitive to acid.  The middle layer which is the functionally important layer is comprised solely of muscle.  It is the contraction of this muscle layer that propels food from the throat down the esophagus into the stomach (swallowing).  The terminal 2-3 inches of this muscle layer ends down by the stomach and functions as a valve that keeps contents of the stomach from coming back up into the esophagus. This area of muscle relaxes only when swallowed food reaches the end of the esophagus, or during vomiting.

As indicated, the contents of the chest are separated from the contents of the abdomen by the muscles known as the diaphragm.  The esophagus must pass through a "hole" (or hiatus) in the diaphragm muscles in order to enter the abdomen.  Normally the diaphragm muscle wraps around the esophagus from both the front and the back as it enters the abdomen, forming a crossing like wrap of muscle that keeps anything except the esophagus from passing through the chest into the abdomen.

When a person has a laxity or anatomic abnormality of the way the diaphragm muscle wraps around the esophagus, the terminal portion of the esophagus and a portion of the upper stomach can protrude through this opening (hiatus) into the chest.  This protrusion is called a hiatal hernia.

Hiatal hernias can be congenital; that is, the diaphragm muscle wrap was defective in the way it formed as a fetus. Or they can be developmental, that is, the diaphragm wrap around the esophagus develops laxity over time as we age. 

There are two types of developmental hiatal hernias. One type is called a sliding hiatal hernia and occurs when the terminal esophagus or upper stomach slides through the lax opening of the diaphragm into the chest.  Usually this occurs with swallowing when the esophagus contracts; but sliding hiatal hernia can reside within the chest continuously. Sliding hiatal hernias are far and away the most common form. The second type of developmental hiatal hernia is called a paraesophageal hiatal hernia.  With a paraesophageal hiatal hernia the terminal esophagus and upper stomach remain in normal position but another portion of the stomach bulges through the hiatus alongside the esophagus.

Hiatal hernias are more common in women, people over age 40 and the obese; and are present in as many as 15% of Americans. The majority of people with a hiatal hernia have no symptoms and would not know they had the condition unless it was seen on a chest x-ray, upper GI x-ray or at endoscopy.     

When people have symptoms from their hiatal hernia it is usually from the backwards passage (reflux) of acid from the stomach up into the esophagus.  In contrast to the lining of the stomach which is designed to produce and adapted to be protected from strong stomach acid; the thin lining layer of the esophagus is not designed to be exposed to stomach acid.  When the esophagus is exposed to stomach acid it can produce symptoms from gastroesophageal reflux disease, know by the acronym GERD.

Less commonly, but importantly, people who have a paraesophageal hiatal hernia can have the portion of the stomach that protrudes into their chest gets stuck and has its blood supply compromised.  This results in a medical emergency requiring urgent reduction of the hernia.

Treatment of hiatal hernia depends upon the symptoms produced, if any.  People rarely need any therapy for hiatal hernias that do not produce symptoms.  For people whose symptoms result from the GERD - burning, belching, upper abdominal discomfort - treatment is almost always successful nonsurgically with medications known as proton pump inhibitors (Nexium, Prevacid, Prilosec Protonix) or H2 antagonists (Pepcid, Tagamet, Axid); antacids (Tums, Rolaids, Mylanta, Maalox), dietary discretion (avoiding alcohol and spicy foods as well as aspirin and ibuprofen), weight loss and avoidance of lying down for several hours after eating.  Rarely, when an aggressive medical regimen fails, surgery may be required.

Treatment for entrapment (incarceration) of a paraesophageal hiatal hernia almost always involves surgery as the interruption of the blood supply of the entrapped stomach or other abdominal organ will eventually lead to rupture and serious complications that could ultimately result in death.

This article is intended to provide useful information, not medical advice. This information cannot, and is not meant to, replace consultation with your physician regarding your individual circumstances.