Hiatal Hernia

The Gastrointestinal Tract (GIT) begins with the oesophagus (swallowing tube). The oesophagus lies within the chest, while the stomach lies within our abdominal cavity. A muscle known as the diaphragm separates the two organs. The oesophagus continues through an opening in the diaphragm, also known as the hiatus, into the stomach. A hiatal hernia occurs when there is a weakness of the hiatal muscles and the stomach bulges up into the chest through the hiatus.

There are two main types of hiatal hernias:

1. Sliding hiatal hernia
In a sliding hiatal hernia, the upper part of the stomach and the lower part of the oesophagus slides up into the chest through the hiatus, along the direction of the oesophagus. This is the most common type of hiatal hernia and accounts for about 95% of all hiatal hernias.

2. Paraoesophageal hiatal hernia
In a paraoesophageal hiatal hernia, the upper portion of the stomach moves up into the chest, through the hiatus, to lie alongside the oesophagus, and can twist more easily. This is a much rarer form of hiatal hernia but it may be more dangerous as the blood supply to the stomach may be cut off when there is twisting of the herniated stomach, which can lead to serious complications such as gangrene of the stomach and perforation.

Patients may not have symptoms, and of those who do, the symptoms may vary depending on the type of hiatal hernia they have. Patients with sliding hiatal hernias usually have symptoms that are similar to Gastroesophageal Reflux Disease (GERD). This happens when acid produced in the stomach and food residue moves up into the oesophagus, causing symptoms like:

1. Burning sensation and discomfort in the lower chest region, commonly known as “heartburn”
2. Regurgitation of food residue into the mouth after eating
3. Recurrent burping
4. Chronic sore throat and cough
5. Bad taste or smell in the mouth
6. Difficulty swallowing

Patients with paraoesophageal hiatal hernias experience symptoms when the blood flow to the portion of stomach trapped in the chest is compromised or when the herniated stomach presses on other organs in the chest. These include:

1. Chest or upper abdominal pain
2. Shortness of breath or difficulty breathing
3. Vomiting
4. Difficulty swallowing
5. Bleeding (e.g. black stools or vomiting of blood)

While the exact causes of hiatal hernia are not known, several factors may contribute to the development of hiatal hernia. These include:

1. Being born with a larger hiatal opening than usual.
2. Trauma to the diaphragm.
3. Weakness of the diaphragm muscles due to age.
4. Rise in abdominal pressure from factors like obesity, pregnancy, chronic straining and coughing.

A hiatal hernia is usually diagnosed via an endoscopy, where a camera attached to the end of a flexible tube is passed through the mouth into the patient’s oesophagus and stomach. A diagnosis can also be made with other imaging studies like chest x-ray, barium swallow, CT or MRI scan of the abdomen and chest.

The recommended treatment for hiatal hernia depends on the type of hiatal hernia and symptoms experienced. , No treatment is needed for patients with sliding hiatal hernia if the patient has no symptoms, and the hernia was found incidentally while being investigated for other conditions. Treatment for a patient with GERD symptoms can be classified into:

1. Lifestyle advice: Losing weight, eating smaller meals and not lying down or sleeping immediately after eating.


2. Medications: There are medications to reduce acid production in the stomach and to help the stomach empty its contents into the small intestine faster. This results in a rapid relief of GERD symptoms. However, they may have to be taken on a long-term basis to remain effective.


3. Surgery: This can be considered for patients who are not keen to take medication over a long term. Surgery involves repairing the loose hiatus, and wrapping a portion of stomach around the same area to reinforce the repair. This is carried out using minimally invasive techniques where small incisions are made on the skin to access the abdomen and perform the surgery. Patients who undergo surgery may need to be on a special diet for a period of time after surgery.

Patients with a paraoesophageal hiatal hernia would have to undergo surgery to be treated. Even if the patient does not experience any symptoms, surgery may be discussed if the patient is fit. This is due to the risk of complications that can occur with paraoesophageal hiatal hernia.