You're getting a little older. You've gained several pounds over the past couple of years. Lately, you've noticed a bit of heartburn after you eat, and on some mornings, when you get out of bed, you're troubled by a burning sensation in your throat. You go to see your doctor, and she says you may have a hiatal hernia. She suggests that you lose weight, offers you a prescription, and tells you to come back in a month for "further tests" if you're not feeling better.
One of the most frustrating things about a visit to a physician these days is the lack of opportunity to ask questions. Doctors are busy individuals, and they tend to speak a language that is unfamiliar to many of us. They often assume that we know what they're talking about as they hand us that little slip of paper, squeeze our shoulder, and head down the hall to their next patient. Unfortunately, our confusion about a diagnosis or our misinterpretation of what a doctor says often leads to less effective treatment.
You walk out the clinic door, wondering what a "high anal" hernia is.
So, let's get a better look at this condition. A "hiatus", anatomically speaking, is a fissure, cleft, or opening in a structure. The best-known hiatus is the one found in our diaphragm, which is a domed sheet of muscle that serves as the floor of our chest cavity - and the roof of our abdominal cavity. Above the diaphragm (in the chest) are the heart and lungs; the esophagus, the tube that leads from the mouth to the stomach, passes through the chest cavity on its way to the stomach, exits the chest by passing through the hiatus, and connects to the stomach directly beneath the diaphragm.
A hernia is produced whenever an organ or tissue protrudes through an opening into an area where it doesn't belong. Most people are familiar with the inguinal hernias that develop in the groin, when a small loop of bowel protrudes through the lower abdominal wall and creates a mass that sometimes needs to be surgically repaired. Likewise, a hiatal hernia is formed when a portion of the stomach pushes through the hiatus in the diaphragm and enters the chest cavity. It cannot be seen from the outside of one's body.
There are two types of hiatal hernias: sliding and rolling. In the sliding type, the junction between the stomach and the esophagus slides upward into the chest, dragging the stomach behind it, much like a child pulling a wagon. In rolling hiatal hernias, the esophagus remains in its usual location, but the upper part of the stomach "rolls" past and migrates into the chest cavity.
A significant number of people with hiatal hernias never have any symptoms; their hernias are discovered when they are being examined for other reasons (many hiatal hernias are "accidentally" found on chest X-rays). When symptoms do occur, they are identical to those in people with gastroesophageal reflux disease (GERD): heartburn, regurgitation, belching, bloating, cough, a sensation of burning in the throat, and - because stomach contents are occasionally inhaled into the lungs - asthma. Some people also complain of difficulty swallowing (their food seems to stick in their chests); bad breath is also common.
Treatment for a symptomatic hiatal hernia mirrors that for GERD: Eating smaller, more frequent meals usually helps, and it is best to avoid eating at all for three to four hours before retiring. Elevating the head of the bed on blocks helps keep stomach contents from regurgitating into the hernia pouch. Antacids usually help, as does avoiding alcohol, nicotine, and caffeine. Since extra weight in the abdomen creates an upward pressure against the stomach, weight loss may be useful. Both prescription and over-the-counter medications are available that reduce acid production in the stomach. Proton pump inhibitors, such as Prilosec, Axid, or Protonix, or H2 blockers like Zantac or Tagamet are all useful in controlling symptoms. Some people benefit from herbal approaches, like slippery elm, licorice root, or marshmallow (the plant, not the puffy white confection).
Once in a while, symptoms cannot be controlled with medications, herbs, or lifestyle changes. Individuals with severe problems often undergo endoscopy, where a flexible scope is passed from the mouth to the stomach to evaluate the hernia. Occasionally, such patients need surgery to repair the hiatal hernia and prevent further symptoms. Nowadays, these surgeries can often be done through a laparoscope.
Hiatal hernias are common, and they are often symptomatic. Lifestyle changes are an important part of management, but medications, herbs, and even surgery are available for those who suffer from this condition.