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Hiatus hernia

Introduction

Hiatus hernia also affects 15-20% of Australian adults, and is closely related to reflux symptoms, particularly regurgitation. Hiatus hernia increases as patients become overweight. Even if patients take PPI medicines to decrease their stomach acid, they will still regurgitate stomach juice into their oesophagus, often causing ongoing symptoms.

Causes

Like all hernias in the body, hiatus hernia is associated with an imbalance in the types of collagen (strong tissue proteins) in the body. This can make the body’s tissues weak. Chronic coughing and heavy lifting can contribute to their development. Weight excess is a common contributing factor.

Symptoms

Whilst most patients with a hiatus hernia do not get severe reflux symptoms, those that do tend to be less responsive to PPI medicines. This is because these medicines do nothing to change the mechanical problem where the junction between the oesophagus and stomach has protruded up into the chest. Patients with hiatus hernia who do get symptoms tend to find that regurgitation of stomach juices is the most prominent symptom. This can often cause significant sleep disruption and have a major negative influence on a person’s quality of life. For this reason, this subset of patients do particularly well with laparoscopic antireflux surgery. There is no ‘one size fits all’ description for patients’ symptoms. People with hiatus hernia can experience any combination of the usual typical (heartburn, regurgitation, dysphagia) or atypical (affecting the voice, taste, throat, ears, lungs, teeth) reflux symptoms.

Tests

Hiatus hernia is usually diagnosed during an upper endoscopy, often for investigation of reflux symptoms. Upper endoscopy is a simple and very safe test performed as a day case under sedation. This endoscopy helps to exclude other more serious problems (eg cancer), but also helps to define the size of the hernia and any other problems, such as Barrett’s oesophagus, which may influence your subsequent management. Depending on these endoscopy results and your symptoms, more detailed testing may be necessary:
  • Oesophageal pH studies (acid testing) and manometry (pressure testing): these clarify more accurately whether or not reflux disease or food pipe dysfunction are causing your symptoms.
  • Barium swallow: dye swallowing test done in an Xray department.
  • Nuclear Medicine study: used when looking for laryngopulmonary reflux (LPR), when other tests have been normal.

Diagnosis

Diagnosis of hiatus hernia with associated reflux symptoms can usually be made from a detailed history. If your symptoms are atypical, don’t respond to PPI medicines, and the endoscopy test is normal, the diagnosis can sometimes be more difficult to make. This is when more advanced testing is required.

Related Information

Reflux and heartburn
Laparoscopic fundoplication