Hiatal Hernia
Dr. Siegal is a fellowship trained upper GI surgeon with specialization in hiatal hernia repair. He proudly offers minimally invasive hiatal hernia repair to all of Southwest Florida including Fort Myers, Naples, Cape Coral and happily accepts patients nationwide including virtual consultations.
What is a Hiatal Hernia?
A hiatal hernia occurs when part of the stomach pushes through (herniates) the esophagus hole in the diaphragm (hiatus). When a portion of the stomach moves up into the chest cavity through this opening, it’s called a hiatal hernia. Hiatal hernias can vary in size and severity, and while some people experience no symptoms, others may deal with discomfort and digestive issues due to the hernia’s impact on the normal functioning of the stomach and esophagus.
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Hiatal hernias are relatively common, particularly in older adults. Studies estimate that around 10-60% of adults in the United States may have some form of hiatal hernia.
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There are two main types of hiatal hernias. The most common type is a sliding hiatal hernia, where the stomach and the lower part of the esophagus slide up into the chest and then return to their original position. The second type, known as a paraesophageal hernia, is less common but more symptomatic. In this form, part of the stomach moves into the chest alongside the esophagus and can potentially lead to acid reflux, nausea, vomiting, ulcers, bleeding, or twisting of the stomach.
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​The likelihood of developing a hiatal hernia increases with age, as the diaphragm muscle tissue naturally weakens over time, making it easier for the stomach to push through.
What Are the Risk Factors?
Age is a primary factor, as the muscles of the diaphragm tend to weaken over time. Extra pressure on the abdomen, which in turn can force the stomach through the hiatus is a risk factor, therefore in patients with obesity or in pregnancy. Similarly, lifestyle factors such as smoking can weaken the diaphragm muscle and increase susceptibility to a hiatal hernia.
Other risk factors include chronic conditions or behaviors that increase abdominal pressure. For instance, individuals who frequently cough (as seen in chronic respiratory conditions), lift heavy objects, or strain during bowel movements are at a higher risk. While there’s no specific genetic cause, a family history of hiatal hernias may also suggest a predisposition.
What symptoms come from a hiatal hernia?
Hiatal hernias can be asymptomatic, but when symptoms do occur, they often mirror those of gastroesophageal reflux disease (GERD) because the hernia can disrupt the normal valve function between the esophagus and stomach. Common symptoms include heartburn, regurgitation of food or liquids into the mouth, difficulty swallowing, chest pain, and bloating. In some cases, a hiatal hernia can cause more severe symptoms, such as shortness of breath or pain that mimics heart issues, leading individuals to confuse the symptoms with a cardiac problem.
Left untreated or unmanaged, a hiatal hernia can lead to chronic GERD, where acid from the stomach frequently irritates the esophagus. This can result in esophagitis (inflammation of the esophagus) and, over time, may lead to more serious conditions, such as Barrett’s esophagus—a precancerous condition that raises the risk of esophageal cancer. In cases of paraesophageal hernia, there is a risk that the stomach may become “strangulated,” or lose its blood supply, which requires emergency medical attention to prevent tissue death.
How is a Hiatal Hernia Diagnosed?
The diagnosis of a hiatal hernia typically involves a combination of patient history, physical examination, and imaging studies. If a person presents symptoms such as heartburn, chest discomfort, or difficulty swallowing, a physician may suspect a hiatal hernia and order tests to confirm it.
One of the primary diagnostic tools is upper endoscopy (EGD). During this exam, a flexible tube with a camera is inserted through the mouth and down into the esophagus and stomach, allowing the physician to inspect the area directly for signs of herniation or damage from acid reflux. At this time, Dr. Siegal will likely do acid reflux testing to see if the patient has GERD. In some cases, esophageal manometry might be used to assess the function (motility) of the esophagus, which can indicate the impact of the hernia on esophageal function.
How is a Hiatal Hernia Treated?
Treatment for a hiatal hernia depends on the severity of the symptoms and the type of hernia. Many individuals with a hiatal hernia do not require treatment if they have minimal or no symptoms. For those who do experience symptoms, lifestyle modifications and medications (PPIs) are often the first line of treatment for heartburn.
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When acid medications do not eliminate symptoms, patients desire to come off medications (concern about side effects) or if the hernia is causing significant complications (Barrett's esophagus, difficulty swallowing, nausea, vomiting, etc), surgery should be considered.
The most common surgical approach is laparoscopic/robotic hiatal hernia repair with fundoplication, in which the stomach is returned to the abdominal cavity where it naturally should be and a reinforcement of the reflux sphincter valve is completed.
