Hiatus hernia

A hiatus hernia is when part of the stomach slides through the diaphragm into your chest. Hiatus hernias are common.

Symptoms

Often, a hiatus hernia won't cause you any symptoms. However, it may cause a feeling of warmth or burning in your chest, which is called heartburn. This happens when the contents of your stomach, which are acidic, flow backwards (reflux) into your oesophagus. If heartburn symptoms go on for a long time or are severe, this is called gastro-oesophageal reflux disease (GORD).

The irritation to your oesophagus caused by reflux can cause pain or discomfort behind your breastbone (sternum).
Your symptoms may start or get worse after you have eaten, soon after you lie down or when you bend forward. Drinking coffee or other hot drinks, or eating spicy food can make these symptoms worse.

If you have these symptoms you should contact us.

Complications

Occasionally, a hiatus hernia can lead to more serious problems. Unlike the stomach, the lining of the oesophagus isn't designed to withstand acid. Reflux of the acidic stomach contents into the oesophagus can damage the lower end of the oesophagus. This is made more likely by a hiatus hernia and can damage the lower end of the oesophagus. This makes symptoms worse and can lead to the formation of ulcers (breaks in the lining of the oesophagus). If your ulcers bleed, you may vomit blood. You should seek urgent medical treatment if you ever see blood in your vomit.

A bleeding ulcer can also lead to anaemia, a condition when you have too few red blood cells or not enough oxygen-carrying haemoglobin in your blood. In the longer term, when ulcers have healed they can lead to narrowing (stricture) of the oesophagus, which can cause difficult, painful swallowing and regurgitation of food.

The blood supply to the stomach can also be affected if a segment of the stomach gets tightly trapped in the chest area; this is known as strangulated hernia. With rolling hiatus hernia, the stomach can become blocked, leading to pain and vomiting.

Causes

The exact cause of hiatus hernia isn't known. However, hernias tend to happen when there is some stretching of the tough fibres that normally hold the gastro-oesophageal sphincter in place. The muscles of the diaphragm may also become more flexible. Both of these probably occur with increasing age. About one in three people over 50 will have a small hiatus hernia, probably without symptoms.

Anything that increases the pressure inside the abdomen can increase the size of the hernia. Factors that increase the abdominal pressure include:

• pregnancy 
• being overweight or obese 
• straining to pass urine (eg men who have prostate trouble) 
• having a long-term cough (eg smoker's cough)

Diagnosis

The best way to diagnose a hiatus hernia is via Endoscopy. Your doctor can look at your hiatus hernia through a long, thin, tube-like instrument called an endoscope. This is passed through your mouth or nose and then swallowed. Your doctor can also use the endoscope to look closely at any sore spots or ulcers at the lower end of your oesophagus. He or she can then take a sample of tissue (a biopsy) for a closer examination in a laboratory, if needed.

You may also be asked for a sample of blood to check for anaemia, which can be a sign of blood loss.

Treatment

Self-help

You can reduce the symptoms of your sliding hiatus hernia and prevent it causing you more problems by making these lifestyle changes:

• eat small frequent meals rather than occasional large meals 
• try not to have spicy foods, coffee and alcohol as these can make your symptoms worse 
• don't go to bed on a full stomach 
• wear loose-fitting, comfortable clothes
• if you smoke, try to stop - smoking increases the risks of reflux problems 
• lose weight if you are overweight or obese 
• sleep propped up on plenty of pillows or with the head end of the bed raised by about 10cm
  

Over-the-counter medicines

Antacids

Antacids can be taken in either in liquid or tablet form. Those containing magnesium or aluminium generally work by neutralising the stomach acid. Others contain an ingredient called an alginate, which forms a barrier that floats on the top of the stomach contents and prevents them splashing back up into the oesophagus. Many of the antacids contain a mixture of ingredients. Examples of antacid brands include Mylanta and Gaviscon.

Acid-blocking medicines

If antacids don't work for you, or you need to take large quantities to get relief, your doctor or pharmacist may recommend one of the more powerful acid-blocking medicines. H2 blockers are one type of over-the-counter medicines that cut the amount of acid that the stomach produces. Examples are famotidine and ranitidine (Zantac). Another type of medicine, known as a proton-pump inhibitor, completely stops acid production. An example is omeprazole (Losec).

Prescription-only medicines

If you need to take medicines for indigestion regularly, more than two or three times a week for example, you should discuss you should contact us for an appointment.

Surgery

Rarely, a sliding hiatus hernia causes such severe symptoms or complications that your doctor will recommend surgery. If you have a rolling hiatus hernia, you are more likely to need surgery. Surgery involves pushing the stomach back into the correct position and securing it there, before repairing any gap in the diaphragm. The procedure can usually be done by keyhole surgery although open surgery (through a cut in the abdomen) is sometimes needed.