Hiatal and Para-esophageal Hernia Denver
What is a Hiatal Hernia?
A hiatal hernia occurs when the upper part of the stomach goes up through the opening in the diaphragm (the muscle that separates the chest and the abdomen) that is normally occupied by the esophagus. Physicians often use the phrases “hiatal hernia” and “esophageal reflux” interchangeably. Esophageal reflux is a clinical diagnosis which is based on symptoms, such as heartburn or acid reflux, and is confirmed by tests that evaluate the extent of reflux of gastric juice and acid into the esophagus. A hiatal hernia is a diagnosis of an anatomic change that can only be made by x-ray studies or upper endoscopy.
The drawings below illustrate how the development of a hiatal hernia leads to unfolding of the valve mechanism, resulting in a funnel-shaped valve that increases the ability of stomach contents to reflux back into the esophagus (large arrow on right).
Many patients are told that they have a hiatal hernia when they complain of gastroesophageal reflux (GERD) symptoms, or when the hernia causes pain in their upper abdomen like how groin hernias cause pain in the groin area. Most smaller hiatal hernias (less than roughly 6 cm or 2.5 inches in size, such as the one illustrated above) do not cause pain. Very large hiatal hernias and paraesophageal hernias can cause upper abdominal or chest pain. When pain occurs, surgical repair may be needed to prevent strangulation of the stomach. For the most part, hiatal hernias weaken the effectiveness of the antireflux barrier and increase the severity of gastroesophageal reflux disease.
Is a hiatal hernia serious?
Most hiatal hernias do not cause symptoms or present a danger. The esophagus has to go through the diaphragm through an opening called the hiatus. This opening can get larger, creating a hiatal hernia. Most hiatal hernias are diagnosed when we are working up symptoms of reflux. The diaphragm helps the valve between the stomach and esophagus work. It is common in people with a hiatal hernia to experience reflux as the valve cannot work as well.
Some hiatal hernias can become quite large- called a paraesophageal hernia. This type of hiatal hernia can become serious and require surgery to repair it- regardless of if you have symptoms.
What is the best treatment for hiatus hernia?
The only way to fix a hiatal hernia is surgery. Most of the time surgery is not necessary unless they have symptoms of reflux. If someone has reflux and proceeds with surgery to help their reflux, the hernia is fixed a that time.
What causes a hiatal hernia?
We don’t quite know the full answer to this. Recent studies have shown a collagen defect in the diaphragm in patients with a hiatal hernia. Over time, and as we age, our tissues become weaker; a small hernia can become a larger hernia.
How do you fix a hiatal hernia?
The only way to repair a hernia is surgically
Large or Giant Hiatal Hernias
Large or giant hiatal hernias often cause a portion of the stomach to be up in the chest and can result in reflux or other problems including chest pain, food sticking, painful upper abdominal bloating, and the feeling of getting full early or shortness of breath, especially after eating.
They can also cause chronic blood loss leading to anemia. In these instances, if evaluation indicates that these symptoms are likely due to the hiatal hernia, then surgery to repair the hiatal hernia is needed. Surgery is usually performed laparoscopically and patients are usually able to be discharged the same day. At Institute of Esophageal and Reflux Surgery, we repair over 50 large and/or paraesophageal hiatal hernias a year, with almost all of them being performed laparoscopically.
Paraesophageal hernias are one type of large hiatal hernia and occur when the stomach slides up beside the esophagus (see diagram below). In these situations, the stomach may twist and lose its blood supply or obstruct. Symptoms of paraesophageal hernias often include bloating and chest pain. Surgery may be necessary in these situations to prevent loss of the stomach, and occasionally this surgery needs to be done on an emergency basis. The surgical repair is similar to that described above for large hiatal hernias.
Improved Results with Hiatal Hernia Repair
At Institute of Esophageal and Reflux Surgery, we are involved in a clinical trial to evaluate the effectiveness of the LINX Reflux Management System in patients with paraesophageal hernias. Short term data shows excellent durability with minimal side effects.
Hiatal Hernias Associated with GERD
When a hiatal hernia leads to deformation of the antireflux barrier, it is repaired by performing a laparoscopic fundoplication. In some patients, we can repair the hernia and place the LINX Reflux Management System.
GERD in Which There Is Minimal Hiatal Hernia
Although up to 90% of patients with GERD have a hiatal hernia, the degree of that hiatal hernia is variable, and in many patients the hiatal hernia is fairly minimal (less than 2cm in height). In this situation, there are other surgical techniques (Transoral Incisionless Fundoplication (TIF) and LINX Reflux Management System) that have lower side effects and are very effective in the improvement of symptoms.
What should I avoid eating with a hiatal hernia?
There are not any diet restrictions for a hiatal hernia. If your hernia is at a point where a special diet has ben recommended, then you should consider surgery.
If you have reflux and certain foods do not agree with you, then avoid those foods. Interestingly, there are no studies that show avoiding certain foods (like chocolate, red wine, tomatoes, citrus, etc) if you have reflux makes any difference in reflux. If you drink red wine and it does not bother you- there is no need to avoid it. Foods do not make reflux worse.
What can happen if a hernia is not treated?
Again- most hernias do not need to be repaired. There are certain paraesophageal hernias that we would recommend repairing as they have a risk of twisting. If this happens, it is an emergency and you could loose your stomach and in a small percentage of patients- die.
What problems can a hiatal hernia cause?
Large hiatal hernias/paraesophageal hernias can cause chest pain- especially after eating, shortness of breath, early satiety (getting full quickly).
Is hiatal hernia a serious surgery?
Almost all of our patients go home the same day. There is a special diet to follow depending on the procedure. Most patients are on narcotics for a few days, then transition over to Tylenol/advil. No strenuous activity for about a month as we do not want to stress the diaphragm.
The most important thing in considering surgery is to see a surgeon who specializes in treating hiatal hernias. There are multiple studies that show much better outcomes if your surgeon is a specialist in foregut (diseases of the stomach and esophagus which includes hiatal hernias). Dr Bell has performed over 4000 hiatal hernia repairs, and performs approx. 250 a year- see a specialist.