A hiatus hernia is when part of the stomach is pushed (herniated) into the lowest part of the chest through an opening (the hiatus) in the diaphragm. In most cases, the portion of stomach is pushed across the hiatus in a vertical direction and may move up and down producing a sliding hiatus hernia. In less than 10% of cases the stomach may herniate next to the gullet or oesophagus leading to a rolling or para-oesophageal hernia. Hiatus hernias can affect anyone, but they are more common in people who are over 50 years of age, overweight or during pregnancy.

Many people with a hiatus hernia are unaware of it but it may be associated with gastro-oesophageal reflux disease (GORD) due to the movement (reflux) of stomach acid into the gullet. The commonest symptom of GORD is heartburn; other symptoms may include food regurgitation, a bitter or sour taste, bad breath and prolonged coughing. These symptoms occur because the hiatus hernia weakens the barrier between the top of the stomach and the bottom of the gullet (lower oesophageal sphincter complex)

In some patients with GORD and a hiatus hernia, the oesophagus is exposed to long periods of acid induced inflammation that may lead to erosive oesophagitis or even, Barrett’s oesophagus, a condition whereby the lining of the gullet changes its appearance in response to long-standing and regular acid-induced damage.

So how can this all be diagnosed? Most commonly a patient will have an  Upper GI endoscopy whereby a flexible tube is guided carefully and slowly through the mouth and into the stomach and duodenum. This allows the gastroenterologist to examine the lining of the oesophagus, stomach and duodenum (first portion of the small intestine). Alternatively, a barium swallow may be undertaken in the XR department.

How can this condition be treated? Lifestyle changes and medications are the preferred treatments. Lifestyle suggestions include:

• Adapting eating habits, eating smaller meals more frequently
• Avoiding lying down for 3 hours after eating or drinking
• Removing any foods or drinks from your diet that make symptoms worse

There are two classes of medication that supress acid secretion – histamine-2 receptor antagonists (H₂RAs) and proton pump inhibitors (PPIs). H₂RAs work by blocking the effect of food on acid secretion whereas PPIs block the enzyme making acid. PPIs have emerged as the most effective therapy for relieving symptoms and improving quality of life, as well as healing and preventing damage to the oesophagus.

If patients fail to respond to PPIs or are intolerant of them, surgical repair of the hiatus hernia may be helpful such as laparoscopic fundoplication or lower oesophageal sphincter augmentation (LINX system). Surgery is particularly effective in patients with a hiatus hernia with regurgitation.

For more information about hiatus hernia and potential treatment options, please do not hesitate to contact Dr. Adam Harris.