Hiatal Hernia (Stomach Protruding into Chest)

Definition

Hiatal hernia is a condition where a portion of the stomach pushes into the chest through the hiatus (an opening in the diaphragm). This is generally seen in older and/or obese people. Normally the esophagus runs through the chest to join with the stomach in the abdominal cavity. The stomach never enters the chest compartment (thoracic cavity).

In a hiatal hernia, there can one of two occurrences. The stomach and the esophagus may prolapse into the chest resulting in sliding hiatal hernia. However, in some cases, the stomach alone can prolapse and the bulge forms adjacent to the esophagus, causing a paraesophageal hernia. This protruding part may get strangulated due to cutting off of the blood supply and lead to complications.

Symptoms

A hiatal hernia is generally a silent condition. For this reason it is usually diagnosed routinely while performing tests, such as an x-ray after barium swallow or endoscopy, for other conditions. Patients with a larger hiatal hernia may present symptoms of gastroesophageal reflux disease (GERD) as the gastric juices can regurgitate into the esophagus. In essence it is the symptoms of GERD that is more prominent than the hernia itself. Symptoms may include :

  • Heartburn
  • Bitter or sour taste in the mouth
  • Belching
  • Dysphagia or difficulty in swallowing

GERD can also cause chest pain over a few hours which may be misinterpreted for a heart attack. However, a heart attack would present with other symptoms such as shortness of breath and dizziness. If there is doubt, it is advisable to consult a doctor and clarify the cause.

Causes

The chest and the abdomen are separated by a large muscle called the diaphragm, the major breathing muscle. The upper part of the esophagus (food pipe) which is in the chest passes through the opening of the hiatus, leading into the stomach, located in the abdominal cavity. The muscles of the hiatus form a sphincter around the food pipe that maintains a natural constriction and prevents the organs on either side from prolapsing. Weakening of these muscles causes hiatal hernia and can occur due to:

  • Wear and tear, as happens during aging or injury.
  • Continuous pressure on these muscles because of :
    – Excess weight in pregnant women and obese subjects
    – Chronic coughing
    – Vomiting
    – Straining for bowel movements in constipated people
    – Lifting heavy objects
  • Congenital (inborn) defects in the formation of hiatus.

Treatment

The goal of treatment is to provide relief from the symptoms of GERD and includes

  • Antacids to neutralize acidity.
  • H2-receptor blockers like cimetidine, famotidine, nizatidine or ranitidine to reduce acid production.
  • Proton pump inhibitors (lansoprozaole and omeprazole) to block acid production.

The H2- receptor blockers and proton-pump inhibitors facilitate healing of the irritated lining of the esophagus. The patients can include lifestyle and home remedies in the treatment regime such as :

  • Eating smaller meals and two hours before sleeping.
  • Avoiding foods that trigger heartburn (chocolates, fried and spicy preparations, alcohol and caffeinated drinks)
  • Lying with the head slightly elevated.
  • Exercising regularly to maintain a healthy weight.
  • Quitting smoking.

When the condition does not improve with medication, surgery may be performed to either pull the stomach back into position or strengthen the hiatal muscles. Surgery is also required if there is strangulation of the herniated tissue.

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