Is a Hidden Hernia Causing Your Heartburn?

A hernia is a protrusion of an organ or tissue into a part of the body where it does not belong. Most people are familiar with the type that appears as a bulge in the groin. Much more common in men than in women, this type (known as an inguinal hernia) occurs when part of the intestine protrudes into the groin, possibly as a result of pressure caused by lifting heavy objects and/or straining during a bowel movement.

What you may not know: There is another type of hernia, called a hiatal hernia, that far fewer people are aware of, even though estimates show that it occurs in up to six out of 10 people over age 60. A hiatal hernia, in which a portion of the stomach protrudes into the chest cavity, usually causes no symptoms, When symptoms do occur, however, they are often misdiagnosed as ordinary heartburn and/ or nausea. Such hernias can be detected only with medical tests, such as a barium X-ray.

When The Stomach Moves

The diaphragm (a dome-shaped muscle that helps with breathing) separates the abdominal and chest cavities. The esophagus passes from the throat through an opening in the diaphragm (hiatus) to the stomach. The diaphragm opening is normally less than one inch across.

In patients with hiatal hernias, the opening is larger—sometimes up to 4.7 inches.

Result: The upper portion of the stomach can poke through the enlarged hole into the chest cavity. As the hernia enlarges, an increasing amount of the stomach may enter the chest. Large hiatal hernias may cause swallowing difficulties, nausea and vomiting.

Very large hiatal hernias, in which a significant portion of the stomach has entered the chest, can sometimes be detected during a physical exam. A doctor may be able to detect bowel sounds inside the chest cavity. In most cases, hiatal hernias can be diagnosed only with a barium X-ray (the patient drinks a chalky liquid that coats—and illuminates—the upper digestive tract) or an endoscopic procedure, in which a doctor uses a lighted tube to view the esophagus and stomach.

Risk Factors For Hernias

Some people have a genetic susceptibility to hernias—they're born with an unusually large hiatus or the opening enlarges due to weakness in the surrounding muscles.

As with inguinal hernias, repeated abdominal pressure—from lifting heavy objects, straining to have bowel movements, being overweight, and/or severe coughing, sneezing or vomiting -may increase risk for hiatal hernias.

Two types of hiatal hernias...

• Sliding hernias are the most common. They occur when a small portion of the stomach (typically about an inch) "slides" into the chest cavity, then returns to its normal position. This movement reduces pressure on the lower esophageal sphincter (LES), a circular band of muscle at the base of the esophagus, allowing reflux (backing up of stomach acid.
  
• Paraesophageal hernias, though quite rare, are potentially more serious. The upper part of the stomach rises until it's next to the LES. This can restrict (strangulate) blood flow in the stomach, which if untreated, can result in necrosis (death) of the stomach. If the necrosis is not treated, it can be fatal.
  

If a paraesophageal hernia causes symptoms, such as chest pain, it should be surgically repaired.

Controlling Heartburn

Without treatment, the chronic surge of stomach acid that occurs in patients with symptomatic hiatal hernias can cause inflammation of the esophagus...iron-deficiency anemia from esophageal bleeding...or premalignant changes (Barrett's esophagus) that can lead to esophageal cancer. Some patients experience difficulty breathing or even severe chest pain that resembles a heart attack.

Most people with hiatal hernias don't require surgical repair as long as they can minimize discomfort and damage caused by the reflux of stomach acid. My advice…

• Make lifestyle changes. Most patients with bernia-related heartburn require medication, but some improve significantly with lifestyle adjustments...
  
• Avoid eating within four to five hours of bedtime. Eating stimulates the production of stomach acid, which is more likely to cause heartburn when patients lie down soon afterward.
  
• Avoid peppermint and caffeine. Both reduce muscle tension in the LES, the muscular band that helps prevent reflux.
  
• Raise the head of the bed about six inches. Gravity can prevent stomach acid from moving into your esophagus while you sleep. Use bricks, wood or plastic risers designed to elevate the head of the bed.
  
• Consider taking medication. For most medical conditions, doctors usually prefer to start treatment with the mildest drugs first. In my experience, the opposite approach-starting strong, then tapering off, if possible-seems to work better for hernia-related heartburn…
  
• Proton-pump inhibitors (PPI) are considered the strongest heartburn medication, so your doctor may advise you to start with one of these drugs. PPIs, such as omeprazole (Prilosec) and esomeprazole (Nexium), inhibit acid production in the stomach and allow damaged tissues to heal. If a PPI taken twice daily improves symptoms within about six weeks, your doctor may suggest that you cut back to one dose a day.
  
• Antacids and H2-blockers. If heartburn symptoms continue to improve over roughly a six-week period, you can probably switch to a milder (and less expensive) drug, such as an Over-the-counter antacid or H2-blocker, including famotidine (Pepcid) or cimetidine (Tagamet), for occasional relief.
  

When To Consider Surgery

Most people with hiatal hernias can control heartburn with drugs alone. Therefore, surgery is recommended only if you have a twisted stomach that endangers your stomach's blood supply...complications, such as scarring or bleeding due to reflux...or severe discomfort or reflux of stomach contents (such as bile or digestive enzymes) that isn't relieved by medications. Surgery also is recommended for patients who no longer wish to take reflux medications.

Most hernias, including hiatal hernias, are repaired with laparoscopic "keyhole" surgery, in which the surgeon inserts a camera and instruments through four or five small (less than half an inch) incisions in the abdomen.

About 95% of patients who receive surgery for hiatal hernias will no longer need medication to control symptoms.