“I have not been well for three months, having a choking feeling in my throat and soreness of the esophagus. Esophagoscopy showed I have a moderate hiatal hernia. Is there any treatment, and what should one do and not do with this illness?”
A hernia occurs when a part of the body slides through an opening into a position that is not its normal position.
The stomach sits in the abdomen immediately below the diaphragm, which is a sheet of muscle that separates the chest from the abdomen. The esophagus (gullet) runs from the back of the throat, down the back of the chest, through the diaphragm and joins the stomach. There is a hole in the diaphragm through which the esophagus passes just before it enters the stomach. If part of the stomach moves up through this hole into the chest cavity, the patient has a hiatus hernia.
Pressure in the abdominal cavity from heavy lifting, obesity, and tension (muscle spasm occurs), or slack ligaments in the diaphragm in the elderly, may all lead to the formation of a hiatal hernia.
Patients usually describe difficulty in swallowing and sometimes pain from ulceration inside the hernia or pinching of the hernia. Further symptoms can include:
- heartburn (which may be very severe)
- burping excessively
- a bitter taste on the back of the tongue (“waterbrash”)
- difficulty in swallowing
- a feeling of fullness
- bleeding from the damaged part of the stomach
- palpitations if a large hernia pushes onto the heart
Most of these hernias are small, but sometimes a large proportion of the stomach may push up into the chest. The heartburn is usually worse at night when lying down, or after a meal. It is usually eased by drinking milk or an antacid, but this relief may only be temporary.
Long-standing reflux of acid into the esophagus can cause peptic ulcers which may bleed and cause serious complications. Most cases of hiatal hernia can be treated with medication, posture and diet.
Antacids that neutralize the acid, liquids and gels that coat the lower esophagus, anesthetic mixtures, foaming granules that float on top of the stomach acid, and tablets that reduce the amount of acid secreted by the stomach (eg, Tagamet, Zantac, etc.) can all be used alone or in combination. Tablets that increase the emptying rate of the stomach, and strengthen the valve at the lower end of the esophagus (eg, Maxolon, Propulsid) are also useful.
Frequent small meals, rather than three large meals a day, and a diet low in fat and high in protein is beneficial. Obese patients must lose weight. Gravity is the most important factor in keeping the stomach in the abdomen rather than the chest, and the acid in the stomach rather than the esophagus. Bending over to garden or lift, and any heavy lifting are banned.
The head of the bed should be elevated, and three or more pillows used to raise the chest higher than the abdomen. Lying on the right side rather than the left, to enhance the drainage of the stomach, can also be tried. In only a small percentage of patients, who do not respond adequately to the above regime, should surgery be contemplated.