Hiatal Hernia

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Dr Chong Choon Seng

MBBS | MRCS | Masters in Medicine (Surgery) | FRCS (Edinburgh)

A hiatal hernia arises when a portion of the stomach protrudes through the diaphragm and into the chest cavity. This occurs via the hiatus, a natural opening in the diaphragm through which the oesophagus passes to connect to the stomach.

The condition is more common in people over the age of 40, with its impact varying widely, from no noticeable symptoms to marked digestive discomfort.

Symptoms of Hiatal Hernia Symptoms of Hiatal Hernia

Symptoms of Hiatal Hernia

The symptoms of a hiatal hernia differ widely among individuals. While some people remain symptom-free, others may experience a combination of the following:

  • Acid Reflux: Stomach acid travels back into the oesophagus, leading to a burning sensation in the chest.
  • Chest Pain: Discomfort behind the breastbone, often aggravated by eating or lying down.
  • Difficulty Swallowing: A sensation of food becoming lodged in the throat or chest during meals.
  • Regurgitation: Food or liquids come back up into the mouth, particularly when bending over or lying down.
  • Shortness of Breath: The herniated stomach can compress lung space, affecting breathing capacity.

Causes and Risk Factors

Several factors can contribute to the development and progression of hiatal hernias. Common causes and risk factors include:

  • Age-Related Muscle Weakening: The diaphragm muscle naturally weakens with age, increasing susceptibility after 50 years.
  • Obesity: Increased abdominal pressure from excess weight can contribute to hernia formation.
  • Pregnancy: Hormonal changes and increased abdominal pressure during pregnancy can lead to hernia development.
  • Trauma: Injuries to the chest or abdomen can weaken or damage the diaphragm.
  • Chronic Strain: Activities or conditions that cause repeated strain, such as heavy lifting or persistent coughing, can lead to diaphragm weakening over time.

Diagnosis of Hiatal Hernia

Barium X-ray

Patients drink a chalky liquid containing barium that coats the digestive tract. X-ray images then reveal the position of the stomach and any abnormalities in the digestive system. Multiple images taken over several minutes show how the hernia behaves during swallowing.

Endoscopy

A flexible tube with a camera examines the upper digestive tract directly. The procedure allows visualisation of the hernia and assessment of any damage to the oesophagus or stomach lining. Tissue samples can be collected if needed.

CT Scan

This imaging technique provides detailed views of the chest and abdomen. The scan shows the exact location and size of the hernia and identifies any complications. This method helps surgical planning when needed.

Manometry

A pressure-sensitive tube measures muscle function in the oesophagus and lower oesophageal sphincter. The test evaluates swallowing ability and sphincter strength, which influence treatment decisions.

Treatment Options

Treatment is determined by the size of the hernia, the severity of the symptoms, and the patient’s overall health. Mild cases often respond well to non-surgical approaches, whereas surgery is required for complications or when symptoms persist despite other measures.

Non-Surgical Treatment

  • Medications: Medications are commonly used to manage hiatal hernia symptoms, especially acid reflux. Antacids provide quick relief by neutralising stomach acid, while H2 blockers help decrease acid production for more sustained control. For more severe symptoms or oesophageal damage, proton pump inhibitors (PPIs) are often prescribed as they suppress acid production effectively and aid in healing. These treatments are typically combined with lifestyle changes to alleviate discomfort and improve symptom management.

Surgical Treatment

  • Laparoscopic Hernia Repair: This minimally invasive procedure involves small incisions in the abdomen through which a laparoscope (thin tube with a camera) and surgical instruments are inserted. The hernia is repaired by repositioning the stomach and tightening the diaphragm opening (hiatus). This method is associated with reduced pain, shorter hospital stays, and quicker recovery compared to open surgery.
  • Open Hernia Repair: In more complex or severe cases, open surgery may be necessary. This procedure involves a larger incision in the chest or abdomen, providing direct access to the hernia. The surgeon repairs the hernia by repositioning the stomach and reinforcing the diaphragm. Although recovery is longer, open repair is sometimes preferred for large hernias or those with complications.

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Prevention and Management

Everyday habits are key to managing symptoms and slowing hernia progression. Keeping a healthy weight lowers pressure on the diaphragm, helping to minimise discomfort. Regular low-impact exercise strengthens core muscles while avoiding activities that strain the abdomen. Eating smaller, more frequent meals and staying upright after eating can help control reflux. Loose clothing reduces abdominal pressure, and giving up smoking supports better healing and decreases coughing, which may aggravate the hernia.

Frequently Asked Questions

Are hiatal hernias reversible without surgery?

The hernia itself cannot be physically reversed without surgical intervention. However, symptoms can often be effectively controlled through a combination of lifestyle adjustments, dietary modifications, and medications designed to reduce reflux and discomfort.

Can hiatal hernias lead to other health conditions?

Generally, most hiatal hernias do not lead to any other severe conditions. However, if untreated and associated with severe acid reflux, it can cause complications such as chronic oesophagitis, Barrett’s oesophagus (a precancerous condition involving changes to the oesophageal lining), or, in rare cases, oesophageal cancer.

How long does recovery take after hiatal hernia surgery?

Recovery time varies based on the surgical approach. For laparoscopic surgery, most patients can resume light activities within a few days and return to normal routines within 2-3 weeks. Recovery after open surgery typically takes longer, with most patients requiring 4-6 weeks before resuming full activity.

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Dr Chong Choon Seng

MBBS (NUS)

MRCS (Edinburgh)

Masters in Medicine (Surgery)(NUS)

FRCS (Edinburgh)

Dr Chong is the former Program Director of General Surgery Residency at NUHS, and has more than 10 years of experience as a colorectal and general surgeon.

As an esteemed professional in minimally invasive surgery, Dr. Chong remains committed to achieving optimal outcomes for all surgical conditions, from piles to cancer treatment.

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