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Why do I have a Hiatal or Paraesophageal Hernia?
Hiatal and paraesophageal hernias are rare but occur when a part of the stomach or other organs bulges through the diaphragm into the chest. This is now thought to be due to weakness in the diaphragm and the development of a hernia that potentially increases in size over time. Studies have shown that the muscle fibers of the diaphragm are weaker in people with hiatal and paraesophageal hernias when compares to patients without these conditions.
The picture above shows the different types of hernias.
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Type I: This is the most common and is defined as a Hiatal hernia. This occurs when the lower esophageal valve (LES) is in the chest and typically slides in an out of the chest. The valve in these situations can be weakened and some patients with have reflux symptoms.
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Type II-IV: These are all paraesophageal hernias. These patients typically will have different parts of the stomach and/or other organs in the chest that should not be there. Sometimes there lower esophageal valve (LES) will also be displaced into the chest. Patients with paraesophageal hernia may present with a range of symptoms from no symptoms to difficulty swallowing, reflux, or chest pain and shortness of breath. Paraesophageal hernias can be dangerous and need evaluation by an expert surgeon or gastroenterologist who can make recommendations.
Many people will not know if they have a hernia unless they have symptoms. Most hernias are not threatening but evaluation by a surgeon and gastroenterologist specializing in these issues is warranted.
Symptoms
Most patients will not have any symptoms from the hernia. However, patients can present with a variety of symptoms which will require further work-up.
Individuals with Hiatal and Paraesophageal hernias present with a variety of symptoms, including:
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Heartburn
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Regurgitation
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Difficulty swallowing
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Hoarseness
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Feeling a lump in the throat
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Excess saliva
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Chest pain
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Bloating
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Early Satiety
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Belching
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Nausea
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Asthma
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Wheezing
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Chronic cough
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Shortness of Breath
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Recurrent Pneumonia
The most common reason to have symptoms is related to a mechanical problem which is related to the valve at the bottom of your esophagus being in the chest and/or the hernia compressing surrounding structures leading to symptoms.
Because this is a mechanical weakness typically there is no way to strengthen that valve without fixing the problem surgically. However, there are steps to reduce or eliminate symptoms through lifestyle and nutrition modifications.
Most patients with reflux will have classic acid reflux when their valve does not work well. The typical symptoms include heartburn, regurgitation of food and chest pain. Some patient will end up having atypical symptoms including hoarseness, sinusitis, asthma, shortness of breath, throat clearing among others listed above.
Most patients who have these symptoms will end up starting some type of medication including proton pump inhibitors, H2 blockers, or agents that coat the stomach to provide adequate relief. You may even take over the counter medications including Rolaids, Tums, and alike. You still need to have lifestyle and nutrition modifications to help with better outcomes.
Nowadays many of the medications to treat the symptoms for reflux are over the counter and do not need a prescription from your doctor. As such a short trail of these maybe reasonable for some patients suffering with reflux. But some patients may require longer therapy for months or years. In these scenarios, it is important to consult with a doctor with expertise in these disorders to assess your condition and perform if necessary diagnostic testing.
Diagnostic Testing
Symptoms alone are insufficient to make the diagnosis and treatment of hiatal and paraesophageal hernias. Most patients will need objective comprehensive diagnostic testing to pinpoint the cause of symptoms. Typically, patient will require at least the following tests to help establish the diagnosis and severity of disease.
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Esophagogastroduodenoscopy (EGD):
The EGD is the most common test for the initial evaluation of reflux. Most gastroenterologist and clinicians with expertise in this disease can perform this test which is usually done in an Endoscopy Suite and takes a short period of time. Most patients will get some sedation to make them comfortable. Routine biopsies are recommended to determine if there are abnormalities in the esophagus concerning for Esophagitis related to reflux or other causes. Clinicians can also evaluate for Barrett's or other changes that may alter management.
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Barium Swallow:
This is an X-ray exam where the radiologist will have you swallow liquids, and solids and shoot live images of your swallow to evaluate for anatomic defects in the esophagus and look for signs of reflux, hernia, and masses pressing on the esophagus.
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Manometry:
This test will determine what the pressures are along your esophagus during swallows. It will detect abnormalities in pressure waves and also function of your valves that may further explain the reason for your symptoms.
This test is typically placed by placing a chip in your esophagus that assessing for acid reflux off medications for 48hours. This test is very good for acid reflux but will fail to assess bile or non-acid reflux. In these scenarios impedance testing using a catheter placed in your nose for 24 hours is used. This test is more uncomfortable and is used only in scenarios where acid testing is inconclusive.