Kansas City Hiatal Hernia Doctors

The vast majority of hiatal hernias are of the sliding type, and most of them are not associated with symptoms. The larger the hernia, the more likely it is to cause symptoms. When hiatal hernias produce symptoms, they almost always are those of gastroesophageal reflux disease (GERD) or its complications. This occurs because the formation of the hernia often interferes with the barrier (lower esophageal sphincter) that prevents acid from refluxing from the stomach into the esophagus. Additionally, it is known that patients with GERD are much more likely to have a hiatal hernia than individuals not afflicted by GERD. Thus, it is clear that hiatal hernias contribute to GERD. However, it is not clear if hiatal hernias alone can result in GERD. Since GERD occurs in the absence of a hiatal hernia, factors other than the presence of a hernia can cause GERD.

Normally, there are several mechanisms to prevent acid from flowing backwards (refluxing) up into the esophagus. One mechanism involves a band of esophageal muscle where the esophagus joins the stomach called the lower esophageal sphincter that remains contracted most of the time to prevent acid from refluxing or regurgitating. The sphincter only relaxes when food is swallowed, so the food can pass from the esophagus and into the stomach. The sphincter normally is attached firmly to the diaphragm in the hiatus, and the muscle of the diaphragm wraps around the sphincter. The muscle that wraps around the diaphragm augments the pressure of the contracted sphincter to further prevent reflux of acid.

Another mechanism that prevents reflux is the valve-like tissue at the junction of the esophagus and stomach just below the sphincter. The esophagus normally enters the stomach tangentially so that there is a sharp angle between the esophagus and stomach. The thin piece of tissue in this angle, composed of esophageal and stomach wall, forms a valve that can close off the opening to the esophagus when pressure increases in the stomach, for example, during a belch.

When a hiatal hernia is present, two changes occur. First, the sphincter slides up into the chest while the diaphragm remains stationery. As a result, the pressure normally generated by the diaphragm overlying the sphincter and the pressure generated by the sphincter no longer overlap, and as a result, the total pressure at the gastro-esophageal junction decreases. Second, when the gastro- esophageal junction and stomach are pulled up into the chest with each swallow, the sharp angle where the esophagus joins the stomach becomes less sharp and the valve-like effect is lost. Both changes promote reflux of acid.

Treatment of large para-esophageal hernias which cause symptoms requires surgery. During surgery, the stomach is pulled down into the abdomen, the esophageal hiatus is made smaller, and the esophagus is attached firmly to the diaphragm. This procedure restores the normal anatomy.

Since sliding hiatal hernias rarely cause problems themselves but rather contribute to acid reflux, the treatment for patients with hiatal hernias is usually the same as for the associated GERD. If the GERD is severe, complicated, or unresponsive to reasonable doses of medications, surgery often is performed. At the time of surgery, the hiatal hernia is eliminated in a manner similar to the repair of para-esophageal hernias. However, in addition, part of the upper stomach is wrapped around the lower sphincter to augment the pressure at the sphincter and further prevent acid reflux.

•  A hiatal hernia is an anatomical abnormality of the esophagus.
• Hiatal hernias contribute to gastroesophageal reflux disease.
• The symptoms in individuals with hiatal hernias parallel the symptoms of the associated GERD.
• The treatment of most hiatal hernias is the same as for the associated GERD.