Introduction 

Hiatus hernia is a common condition that probably affects more than 10% of the population. The “hiatus” is a hole in part of the diaphragm where the oesophagus (gullet) passes through to join the stomach. A “hernia” is where an organ, in this case the stomach, slips from its normal anatomical position (the abdomen), to an abnormal position (the chest).

The most common result is that part of the mechanism that keeps acid within the stomach (rather than allowing it to pass up into the oesophagus) is impaired. Two main varieties of hiatus hernia are recognised. More than 90% are the “sliding” type where a portion of the stomach slips up into the chest.

The minority are more anatomically complicated and potentially dangerous, they are known as “para-oesophageal” hernias. The majority of people with the condition have no symptoms whatsoever, no matter what type of hiatus hernia they have.

Causes of Hiatus Hernia

Enlargement of the oesophageal hiatus in the diaphragm as a result of muscle weakness (possibly with age) and as result of raised pressure within the abdominal cavity due to obesity, chronic cough or straining, allows the stomach to ascend into the chest as its restraining ligaments become stretched.

Symptoms

Symptoms of gastro-oesophageal reflux (heartburn, indigestion, regurgitation and cough) are commonly seen in patients with symptomatic “sliding” hiatus hernia. These symptoms may be worse on lying down, after taking large meals and consuming alcohol.

Patients with “para-oesophageal” hiatus hernia may also complain of such symptoms. Less commonly these patients may present to hospital with severe abdominal or chest pain, anaemia and even complete obstruction of swallowing.

Investigation

Hiatus hernia may be diagnosed by a variety of means but most commonly it is by OGD (Oesophago-Gastro-Duodenoscopy) when investigating gastro-oesophageal reflux. A flexible endoscope is inserted via the mouth into the oesophagus, stomach and duodenum.

CT scanning of the chest and abdomen is used to clarify the appearance of para-oesophageal hernias that may have been detected on chest x-ray or at endoscopy.

Treatment

• “Sliding” Hiatus Hernia
• Proton pump inhibitor drugs (Omeprazole, Lansoprazole etc)
• Weight reduction
• Lifestyle changes: Eating smaller meals earlier in the evening and elevation of the bed head.
• Smoking cessation

“Para-oesophageal” Hiatus Hernia

Surgical correction by returning the stomach to the abdominal cavity and repair of the widened defect in the diaphragm this may be achieved by operation through the chest or more commonly the abdomen. The operation is often amenable to laparoscopic surgery.