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Hiatal Hernia

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Dr. Minocha (http://www.diagnosishealth.com/minocha.htm) is the Professor of Medicine and Director, Division of Digestive Diseases at the University of Mississippi Medical Center in Jackson, MS, and is the author of How to Stop Heartburn; Simple Ways to Heal Heartburn and Acid Reflux.

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Hiatal hernia is the most common form of hernia. Unlike other hernias, not everyone who walks around with it knows the condition is there. The reason is that unlike many other forms of hernias (groin, umbilical etc.), hiatal hernia can not be seen as a bulge from out side.

What is hiatal hernia?

Normally the stomach resides in the abdominal cavity. In hernia, the stomach protrudes through an opening (hiatus) in the diaphragm into the chest cavity, and hence the term hiatal hernia. A part of the stomach

A part of the stomach resides in the abdomen, whereas the rest of it is in the chest. Hiatal hernia is not static, and it may come in and out of chest.

How common is it?

The incidence was believed to be only two percent in the 1920s. However, with improvements in technology leading to increased recognition, the number rose to 15% by 1955. More recently, studies quote the incidence to be as high as fifty to eighty percent of the adult population.

Who gets it?

People of all ages can get this condition; however it is more common with aging. It is rare among young adults, but very common above the age of sixty. The size of hernia increases over time.

Types of hiatal hernia

The most common is the sliding type. Quite simply, a part of the stomach just slides up into the chest cavity. The other major type, although very uncommon, is the Para esophageal type. In the latter, the junction of the esophagus and stomach stays put at the level of diaphragm whereas a part of the stomach protrudes up into the chest. Such a situation must be corrected surgically, since it can lead to a life threatening strangulation of the hernia.

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Acid reflux and hernia

Frequently, the hiatal hernia is associated with acid reflux or heartburn. You can have a hernia without acid reflux and vice versa; frequently the two conditions go together, and we don't know exactly which is the cause and which is the effect.

Some people believe that neither the hernia nor the acid reflux is the cause, but they co-occur because of failure of some different mechanism. When they co-exist, they tend to worsen each other.

For example, the lower esophageal sphincter is supposed to prevent the reflux of stomach contents into the esophagus. When hernia occurs, the sphincter loses the support of the diaphragmatic muscles around it. This weakened sphincter is less efficient in preventing acid reflux from stomach into the esophagus.

The hiatal hernia may also serve as a reservoir from which acid can easily regurgitate into the unprotected esophagus.

Other causes of hernia

Various theories have been expounded, however the exact cause of hiatal hernia remains a mystery. Dietary differences have been implicated since it is very common in the west and rare in Asia and Africa.

Genetics may play a role in the causation. Clustering of hiatal hernia among family members encompassing several generations has been described.

Other theories implicate the weakening of the ligaments attaching the stomach to various adjacent structures. This weakened system permits the stomach to be pushed up into the chest. Such a situation may occur due to pregnancy, obesity and aging etc.

Some experts believe that the hiatal hernia occurs because the esophagus is shortened


pulling the stomach into the chest. The shortening occurs because of malfunctioning of nerves in the lower part of the esophagus.

Problems due to hernia

Just because you have a hiatal hernia does not mean that you have a problem at hand. In fact, they don't cause any problem in most people. In many patients however, acid reflux may worsen.

Patients with hiatal hernia tend to have greater acid induced damage to the esophagus. The sliding of stomach in and out of abdomen may cause friction at the neck of the hernia leading to ulcers. Giant hernias may cause anemia, bleeding and chest pain. Para esophageal hernia is prone to strangulation.


The diagnosis is usually made as incidental finding during upper GI x ray or upper endoscopy.

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Medical treatment

Treatment is only needed if the hiatal hernia is causing problems, and such is not the case in most patients.

If you have both hiatal hernia and acid reflux, make life style changes needed for heartburn, including raising the head end of bed for sleep (not pillows), cessation of smoking, avoiding large meals and foods that predispose to acid reflux, and weight reduction in case of overweight individuals.

Patients may be prescribed acid blocking medications like Zantac, Tagamet, Axid, Pepcid, Prevacid, Prilosec, Aciphex, Protonix and Nexium etc.

Hiatal Hernia Surgery

Need for surgery for hiatal hernia is rare. It is indicated in cases of persistent ulcers and bleeding due to the hernia; very large or symptomatic sliding type hernias and; Para esophageal hernias. The surgeon pulls down the hernia into the abdomen and hooks it up to adjacent structures so the stomach won't escape again into the chest. Usually an anti-reflux procedure is also performed.



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