Hiatus Hernia

The stomach resides in the abdominal cavity. A hiatus hernia is when part or all of your stomach moves into the chest cavity, and lie next to your heart and lungs. Sometimes other organs such as your colon, can herniate into the chest cavity along with your stomach. This can lead to complications such as gastric reflux, difficulty eating food, breathing difficulties or twisting of the stomach. If your stomach becomes twisted, it may lose its blood supply and require emergency surgery.

There are 4 main types of hiatus hernias, as shown in the image:

Hiatus Hernia - Surgery Melbourne

Image courtesy of Adult Chest Surgery 2nd Ed.

Repairing the hiatus hernia is usually performed laparoscopically (keyhole surgery). The stomach and other contents of the hernia need to me pulled back down from the chest into the abdomen. The repair may require the use of a dissolvable mesh in order to stengthen the repair. A fundoplication (click here for more information) is also performed as part of the repair.

Normally your oesophagus is located in your chest cavity and your stomach is located in the abdominal cavity. The chest and abdominal cavity are separated by the diaphragm. There is a hole in the diaphragm that allows the oesophagus to pass through it so it can join the stomach.

What is a hiatus hernia?

There are two main types of hiatus hernias.

1. Sliding hiatus hernia – this is when a small part of the stomach slides up into the chest cavity.
2. Paraoesophageal hernia – there are different types of paraoesophageal hiatus hernias. They can involve other organs apart from the stomach e.g. the colon.

What symptoms will I have?

Many people will not have symptom from a hiatus hernia. Frequently they are diagnosed incidentally either on an X-ray, a CT scan or during a gastroscopy performed for other reasons. Symptoms may include:

- Heartburn: This may be felt behind the sternum (breastbone)

- Reflux: In more severe cases of heartburn, you will notice an acid taste in the back of your throat. You may even regurgitate food or drinks you consumed earlier

- Food getting stuck or difficulty swallowing: Reflux of stomach contents into your oesophagus can result in the oesophagus being exposed to stomach acid. The oesophagus was not designed to be exposed to an acidic environment. As a result, repeated reflux may lead to scarring of the oesophagus and subsequently narrowing of its lumen. This means food will not pass easily.

- Raspy voice: This can be the result of frequent reflux events. Sometimes you will not know or feel that you are having reflux.

- Unexplained cough and chest infections: When reflux events occur, the contents of the reflux can come up to the throat and back down into airways. This can lead to food or drink entering the lungs resulting in cough and chest infections.

How is a hiatus hernia diagnosed?

It is frequently diagnosed incidentally on either an X-ray, CT scan or gastroscopy (performed for other reasons).

Sometimes a chest X-ray or CT will show that part of the stomach is in your chest. Other times a person is having a gastroscopy for another reason, and they are found to have a hiatus hernia. A gastroscopy can sometimes show if you have been having reflux by the way the oesophagus looks. The oesophagus may look inflamed (oesophagitis) or have ulcers. A gastroscopy can also diagnose a hiatus hernia. Depending on your symptoms, it is important to have a gastroscopy to rule out a more sinister cause of your symptoms.

What are the possible complications of a hiatus hernia?

Depending on the type or size of the hiatus hernia, the symptoms and complications can be different. Many people do not have any symptoms at all. Complications can include:

- heartburn

- reflux

- swallowing difficulty

- ulcers +/- bleeding, including vomiting blood

- twisting of the stomach (gastric volvulus). This can be a life-threatening condition needing emergency surgery.

How is a hiatus hernia treated?

The different types of hiatus hernias are treated differently, according to the symptoms you experience. If you have a small sliding hiatus hernia and no symptoms, then you may not need any treatment or medications. If you have a hiatus hernia with reflux, then the first line of treatment is antacid medications. These work by reducing the acidity of the stomach secretions. This means that when you have a reflux event, the stomach contents are less acidic, and therefore less likely to cause inflammation of the oesophagus. The antacids are to be taken either before breakfast, before dinner, or both. It depends on when you have the worst reflux symptoms. They can take about an hour to work.

If you continue to have symptoms of reflux or heartburn despite being on maximum antacid medications, then you may require surgery. Prior to undergoing surgery, you may be required to have a 24-hour pH-manometry study. This involves having a fine tube inserted into your nostril and the other end is located at the bottom of your oesophagus. You will be given a button to press for each time you experience your reflux symptom. It is important to ascertain that your symptoms of reflux are actually due to a reflux event. This means you will have better results after surgery.

If you have a large hiatus hernia that is giving you symptoms, then you will most likely need surgery. What surgery is performed for intractable reflux or hiatus hernia

What surgery is performed for intractable reflux or hiatus hernia

If you do not have a hiatus hernia, but only reflux, then the surgery is called a fundoplication. This is when part of the stomach is used to recreate a valve at the top of your stomach. This, along with other techniques performed at the time of surgery, will aim to reduce the chance of reflux occurring. If you have a hiatus hernia, then the surgery is called hiatus hernia repair. This involved pulling the stomach back down into the abdominal cavity from the chest cavity. Once this is achieved, a fundoplication is performed.

How effective is the surgery?

If surgery is performed for gastric reflux, the surgery is 90-95% effective. The aim is to stop the need to take antacid medications after surgery. Around 5-10% of people will have no change or a worsening of their symptoms.

hiatus hernia

What are the possible risks and side effects?

Every procedure and surgery carry risks and side effects. The side effects associated with this surgery can include:

• Swallowing difficulty: This is usually most common in the first few weeks after surgery. It improves over this time. If it persists, then sometime a dilatation or stretch of the repair is required. Doing this can make you prove to having reflux symptoms again.

• Gas bloat: Most people cannot burp like they used following this surgery. This can mean you will experience the sensation of a bloated stomach. • Delayed stomach emptying: This is a risk of this surgery. It can be due to an underlying condition or as a result of surgery.

Your diet after a fundoplication will need to change. For more information on diet after anti-reflux or hiatus hernia surgery, please click here.

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