Do you also get chest pain? I don't know if it's a hiatal hernia! Shall we talk?

Do you also often get heartburn? Do you feel like you have a sour taste in your throat after eating, or do you sometimes feel like food is coming up your throat? Or do you have difficulty swallowing food, or do you feel like something is stuck in your throat? Although we sometimes don't pay much attention to these, there may be a condition called "Hiatal Hernia" behind these. Don't worry, this is something that happens to many people and is treatable. Today, we will talk about this in detail, as if we were talking to a family member.

What is Hiatal Hernia?

Simply put, a hiatal hernia is when the upper part of your stomach pushes through a small hole in the diaphragm, the muscle that separates your chest from your abdomen. Think of it like a wall. This wall has a small hole (esophageal hiatus) where your esophagus connects to your stomach. Sometimes, when this hole gets a little bigger, part of your stomach pushes through. That's what we call a hiatal hernia. The word hernia means that an organ or tissue pushes through a weak spot in the tissue barrier around it, rather than where it normally is. Hernias are common, and many people experience this hiatal hernia. This usually develops gradually over many years. It's not something that changes all of a sudden.

What are the types of Hiatal Hernia?

There are two main types of hiatal hernias: sliding hiatal hernia and paraesophageal hiatal hernia . Most people have this sliding type.

• Type 1: Sliding Hiatal Hernia

This is the most common type (about 95%) . What happens is that your esophagus (food pipe) comes up through a hole in the diaphragm, where it connects to your stomach (gastroesophageal junction), and then goes back down again. It's like it's slipping. That's why it's called a sliding hernia.

• Type 2: Paraesophageal Hiatal Hernia - Also called Rolling Hiatal Hernia.

In this type, the upper part of the stomach protrudes from the opening in the esophagus, beyond the esophagus. It can look like a ball-like lump.

• Type 3: Mixed hernia

This is like a combination of the two types mentioned above. The esophagus protrudes where it connects to the stomach, and another part of the stomach may protrude at the same time.

• Type 4: Complex hernia

This is a bit rare, and it can be a bit complicated. What happens is that the hole in the diaphragm gets big enough that the stomach and another abdominal organ, for example, part of the intestine, the pancreas, or the spleen, come up along with it.

How common is this condition called Hiatal Hernia?

This is actually more common than you might think, especially as you get older. In a country like America, it affects about 20% of the general population. It is said that by the age of 50, 50% will have this condition, by the age of 60, 60%, and by the age of 70, 70% will have this condition. This condition is also common in Sri Lanka.

What are the symptoms of Hiatal Hernia?

In the case of a sliding hiatal hernia, which many people have, you may not even feel the hernia. It doesn't appear as a lump on the outside like other types of hernias.

Many people with a hiatal hernia do not show any symptoms. However, the majority of those who do have symptoms have symptoms associated with long-term acid reflux disease (Gastroesophageal Reflux Disease - GERD ) .

They are:

• Heartburn : A burning sensation in the chest, especially after eating.
• Noncardiac chest pain : Recurrent chest pain , similar to angina , but not related to the heart .
• Indigestion: A feeling of fullness after eating a small amount of food, accompanied by pain in the stomach.
• Burping and regurgitation: The regurgitation of food, air, and acid into the throat.
• Difficulty swallowing or a lump in your throat.
• Sore throat and hoarseness: The acid in the throat can cause sore throat and change the voice.

But remember, not everyone with a hiatal hernia experiences acid reflux, and not everyone who experiences acid reflux has a hiatal hernia. But if you're experiencing these symptoms more often, it could be a hernia. Other warning signs include:

• Nausea: Nausea can be caused by stomach pressure, acid reflux, or both.
• Shortness of breath:If the hernia compresses the lungs, it may be difficult to breathe.
• Pressure or pain in the upper abdomen or lower chest.

These symptoms are most commonly seen in people with large paraesophageal hernias.

What does Hiatal Hernia pain feel like?

A hiatal hernia is where your stomach and chest meet. So if you have pain from a hernia, it can feel like chest pain or stomach pain. Pain can occur when you do certain things or when you are in a position where the hernia is pressing or pinching. For example, if you have a large hernia, you may experience pain when you bend forward, cough, or lift something. Pain can also be a sign that something is wrong. But most of the time, the pain from a hiatal hernia is not from the hernia itself, but from acid reflux. The acid irritates your esophagus. Because this esophagus runs from the middle of your chest to your throat, the pain can feel like it's radiating up, down, or all over your chest. Most people feel it like a burning sensation. Some people may even feel it like a heart attack. If you have any doubts, or if you experience chest pain, it's best to see a doctor and get checked out.

How does acid get into the throat due to a hernia?

Imagine, where our esophagus connects to our stomach (gastroesophageal junction). That's where the diaphragm goes, and the muscles that normally help stop acid from going up into the throat tighten. When these muscles tighten and can't close the esophagus properly, the acid in the stomach starts to come back up into the esophagus. Also, because of the hernia, some of the acid gets stuck in the upper part of the stomach, and it doesn't go down as easily. This is simply what happens.

What are the causes of Hiatal Hernia?

A hernia can develop when there is a weak spot in the tissues that separate different parts of our body. That weak spot is where the hernia comes out. A hiatal hernia occurs, as mentioned earlier, when the hole in the diaphragm called the esophageal hiatus becomes too large. Sometimes this weakness can occur due to a specific accident, surgery, or a birth defect. But most often it is caused by years of daily stress and strain that have accumulated over time. Anything that creates extra pressure inside your abdominal cavity can put pressure on the diaphragm over time. Here are some of the main factors that can cause a hiatal hernia:

• Prolonged coughing or sneezing: Think about it, some people have a chronic cough. When you cough and sneeze continuously, the pressure inside your abdomen increases.
• Constipation: People who suffer from constipation know this.
• Obesity: If the body mass index (BMI) is greater than 30.
• Frequent vomiting.
• Strenuous exercise or weight lifting: When lifting heavy weights, like at the gym.
• Pregnancy and childbirth: Abdominal pressure also increases during these times.

Is this Hiatal Hernia a serious condition?

Most of the time, no. Most hiatal hernias are not serious. Most don't cause any symptoms. You may not even know you have one. However, a large hernia can become serious over time. If it's large, you will often have symptoms.

What are the possible complications?

The most common problem caused by a hiatal hernia is chronic acid reflux. If this is severe and not properly controlled with medication, it can eventually damage your esophagus. Complications from chronic acid reflux include:

• Esophagitis: Acid reflux into the esophagus causes the lining of the esophagus to swell and become inflamed. This can cause pain, difficulty swallowing, ulcers, and even bleeding.
• Esophageal stricture: Continued injury can cause scar tissue to form in the esophagus. This scarring can interfere with the muscles that work during swallowing, causing the esophagus to narrow.
• Barrett's esophagus: Continuous injury can sometimes cause changes in the lining of the esophagus (a condition called ``Barrett's esophagus.'' Although this is not harmful per se, it is considered a precancerous condition .

Very rarely, complications can occur if a hiatal hernia becomes trapped or pushed into the opening. This usually happens with the less common types of hernia. Such complications include:

• Gastrointestinal obstruction: Your stomach or another organ can become stuck, squeezed, or twisted in the opening, blocking your digestive tract.
• Gastritis: Acid reflux into the herniated part of the stomach can cause swelling, stomach ulcers, and internal bleeding.
• Ischemia: If the hernia is so severely compressed, the blood supply to it can be cut off. This can cause swelling, pain, and eventually tissue death. This is an emergency.

How is Hiatal Hernia diagnosed?

Doctors diagnose a hiatal hernia by looking at images of your esophagus and stomach. Sometimes it's discovered incidentally while looking for something else. However, a doctor may want to look for it if you have symptoms of acid reflux. First, they'll do an esophageal pH test to check for acid in your esophagus.If there is such acid, imaging tests will be done to find the cause. Tests that can diagnose a hiatal hernia include:

• Chest X-ray: This takes still, black and white pictures of the inside of your chest, where the esophagus is located.
• Esophagram / Barium Swallow: This is like a video of your esophagus. It allows you to see the inside of your esophagus in real-time as you swallow. Before this, you will be given a liquid called barium to drink.
• Upper endoscopy: A long tube with a small camera attached is inserted through the mouth to look inside the esophagus and stomach. This allows you to see the inside of the esophagus on a live screen. If necessary, small pieces of tissue (biopsy) can be taken for examination.
• Esophageal manometry: A catheter is inserted into the esophagus to measure the pressure of the muscles in the esophagus.

Will this hernia go away on its own?

No. Hernias don't get better on their own. They usually get better over time. However, that doesn't mean your hernia won't cause you any problems. If you don't have any symptoms from your hiatal hernia, you probably don't need treatment. But if you do have symptoms, they may persist and even get worse. Mild acid reflux can be managed with medication. But more severe cases may require surgical repair.

What are the medical treatments for Hiatal Hernia?

Your doctor will carefully examine the nature of your hernia, the size of your hernia, and your symptoms to determine the best long-term treatment option for you. The options available are:

• Wait and watch: If your hernia isn't bothering you, it may not need treatment. But your doctor will keep an eye on it, as it can get bigger over time.
• Use medications: Medications cannot completely stop acid from coming up into the throat. But they can reduce the amount of acid in the stomach. Then, even if it does get up into the throat, it will cause less damage and reduce the pain.
• Surgery: A minor operation can repair your hiatal hernia. Surgery is an option for everyone, but not everyone needs it. Some people may need it sooner, while others may need it later.

Medications

If you have occasional heartburn, you may find relief with over-the -counter antacids (such as Digene, Gelusil). However, if it is persistent, your doctor may prescribe a long-term, daily medication. This usually includes proton pump inhibitors (PPIs).(e.g. Omeprazole, Esomeprazole, Pantoprazole) are prescribed. These can help prevent acid damage to the esophagus and heal the damaged areas. However, these medications cannot stop food from coming back up into the throat (regurgitation) or stop the hernia from getting bigger.

Surgery

Doctors recommend hernia repair surgery in cases like these:

• If the symptoms or complications caused by your hernia cannot be prevented with medication.
• If medications cause side effects that affect your health or quality of life.
• If your hernia is large enough to cause major complications in the future.

Hiatal hernia surgery corrects the hernia and acid reflux in the following way:

• Your stomach and lower esophagus are brought back into their correct position below the diaphragm.
• The hole in the diaphragm where the hernia occurred is closed.
• The junction between the stomach and esophagus is tightened.

This surgery is called a fundoplication . The name comes from the word "fundus," which refers to the upper part of the stomach. During the surgery, the surgeon takes the fundus of your stomach, wraps it around the lower part of your esophagus, and secures it with surgical clips (staples) or stitches. Think of it like wrapping a scarf around your neck. This tightens the muscle that separates the two organs (the lower esophageal sphincter). Whenever possible, this is done through minimally invasive laparoscopic surgery . That is, surgery that involves inserting a camera and instruments through a few small incisions.

How is recovery after surgery?

Depending on your condition and the type of surgery, you may need to stay in the hospital for a day or two. Recovery from laparoscopic or robotic surgery is usually quicker and easier. This is because it is done through small incisions, rather than through large incisions like open surgery. However, sometimes open surgery is required. Even after you return home, you will need to recover for another two to six weeks. During this time, you may not be able to eat normally due to temporary symptoms and side effects while your surgery heals. Your doctor will prescribe a very limited diet. You will start with liquids, gradually moving to soft foods, and finally to solid foods. It is normal to lose weight after hiatal hernia surgery - usually about 10-15 pounds (4.5-6.8 kilograms).

How successful is Hiatal Hernia surgery?

Hiatal hernia surgery is 90% successful.Most people can stop taking their medications after surgery and live a normal life without the problem of acid reflux. After recovery, you will need to see your doctor at least once a year to check on the repaired hernia and make sure everything is working properly. If any new problems develop or if old problems come back, your doctor will look into those as well. Long-term studies have shown that about 50% of hiatal hernias will recur after a period of time (usually several years) after surgery. This may be because some part of the surgery was not done properly, or because the factors that caused the original hernia are still active and have caused a new one. However, not all hernias that recur will have the same symptoms. However, if they do, a new surgery can often permanently correct them.

What can I do at home for my hiatal hernia?

If you live with a hiatal hernia that causes occasional symptoms, you can try to find relief at home with over-the-counter medications and lifestyle changes. Antacids - such as Tums®, Rolaids®, Pepto-Bismol® (similar drugs are available in Sri Lanka, ask your doctor or pharmacist) - can help control occasional heartburn, but they are not recommended for regular use. You can also reduce the frequency and severity of heartburn with some lifestyle changes. For example:

• Maintain a healthy body mass index (BMI) for you: If being overweight is causing acid problems, losing weight can help.
• Eat smaller meals: Instead of eating a large meal at once, eat smaller meals. This will reduce the pressure on your stomach.
• Reduce oily foods: Foods high in oil and fat cause the stomach to produce more acid and enzymes.
• Eat dinner early: Don't lie down for a few hours after eating. Then gravity will help you.
• Change your sleeping position: Sleeping with your head slightly elevated at night and sleeping on your left side can help prevent acid from coming up into your throat. There are specially designed body pillows for this.
• Quit smoking: Smoking weakens your lower esophageal sphincter. It can also cause a chronic cough, which puts pressure on the muscles around the hiatal hernia.

You may be diagnosed with a hiatal hernia by chance when you go to see a doctor for another reason. This is very common, and if yours is small and not causing you any problems, it is not something to worry about. Or, you may be diagnosed with a hiatal hernia after years of symptoms and finally looking for answers and relief. You may be surprised to learn that your acid reflux is caused by a hernia. Fortunately, there are treatments for both acid reflux and hiatal hernia. The treatment you need will depend on the type of hernia and your symptoms. In many cases, medication and lifestyle changes can help control your acid reflux. In more severe cases, surgery may be needed to repair the hernia. This surgery is very successful. Once your diagnosis is clear, you will be on your way to finding relief from your symptoms.

Finally, things to remember

A hiatal hernia is nothing to be afraid of. Many people have it and don't show any signs.

However, if you continue to have symptoms like chest pain, food coming up in your throat, or difficulty swallowing, you should definitely seek medical advice. Because it's important to know exactly whether the cause is a hiatal hernia or something else and get the necessary treatment.

This condition can be managed well with lifestyle changes and sometimes medication. Even if surgery is required, it is now done with very advanced techniques and has successful results. So, don't panic. Talk to your doctor and find the best solution for you. Hiatal hernia, heartburn, acid reflux, GERD, stomach, esophagus, hernia surgery