Hiatal hernia is the complaint in vogue this decade. More and more people are being diagnosed as suffering from this condition, and it is becoming something of a conversation piece.
What is a hiatal hernia?
Until the last few years, few had ever heard of hiatal hernia (or hiatus hernia). Indeed, apart from an occasional comment from astute doctors, the diagnosis was seldom made.
To the average person, it was non-existent. But with the present knowledge that it is extremely common, and with more accurate radiological techniques and more sophisticated machines, increasing numbers are being picked up.
Yet most people are completely unaware of what a hiatal hernia really is. It means that part of the stomach is being pushed through (or “herniates” by way of a hole in the diaphragm) and enters the thoracic cavity.
The diaphragm is the large sheet of muscle that divides the thoracic cavity (which contains the lungs and heart) from the abdominal cavity below. In order to reach the stomach, the esophagus (the food-conveying tube) must pierce the diaphragm by way of a hole or “hiatus.”
Where the esophagus connects to the stomach is an internal valve, called the esophageal sphincter. This regularly opens as food passes down, allowing it to enter the stomach.
Occasionally this valve is weak, and fluids may regurgitate back from the stomach into the lower end of the esophagus. This is termed “reflux” and is usually a hand-in-hand deal with hernias.
In about 80 percent of hernias, the enlarged hiatus allows the upper part of the stomach to push through the hole into the lower thoracic cavity. These are termed “sliding” hernias, the hernia sliding in and out of the hiatus, depending on posture.
More rarely a “rolling” hernia occurs. Here, a lower portion of the stomach rolls back on itself and protrudes through the hiatus.
Many of the hiatal hernia symptoms are produced by the contents of the stomach refluxing back into the food pipe.
The stomach is very acidic and so the lining of the esophagus is usually burnt and irritated. The discomforts of heartburn and dyspepsia are felt and often become worse on stooping or bending.
Sometimes the irritation is so intense and persistent that an ulcer develops in the esophagus, and cases have occurred in which this has perforated the walls.
In other severe cases, blood vessels have been eroded causing hemorrhages, similar to those occurring with stomach and duodenal ulcers. Blood loss can surreptitiously occur, and for many months or even years, resulting in anemia.
Frequently there is pain behind the breastbone, and this can be aggravated by the intake of hot, spicy foods, alcohol, smoking, condiments, onion, greasy fried foods, hot strong tea or coffee, and rich sauces.
The trouble-makers are very similar to those that aggravate ulcers. Often alkalis bring temporary relief.
Some patients develop ulceration of the stomach or duodenum in conjunction with their hiatal hernia. The additional symptoms of this are much the same in general nature, and will only seem to be an aggravation in pain, discomfort, and food tolerance, especially to the foods mentioned.
Occasionally a person may wake suddenly at night with a choking feeling as some of the refluxed fluid is inhaled unwittingly during sleep.
Sometimes the continual irritation in the lower end of the food pipe can be so severe as to cause fibrous tissue reaction. So a narrowing (or stenosis) of the esophagus may occur. This can make swallowing more difficult and this may be the first indication a person has that all is not well.
A large number of vague symptoms of dyspepsia, and vague abdominal discomfort, are attributed to hiatal hernias. In many, no doubt, it is the true cause. But it is becoming a bit of a whipping post.
If there is no other obvious reason for internal troubles, then the blanket diagnosis can cover a multitude of evils. It’s a great name tag, both for doctors as well as patients.
It is not known how many in the community have a hiatal hernia, but the figure is quite high. One survey indicated that 30 percent of the population that was symptom-free actually had a hiatus hernia! This is an enormous frequency, but whether it is true throughout a given population is not known.
Hiatal hernias seem to be more common in women, and frequently, symptoms first occur during pregnancy when there are added stresses in the abdomen and gastric symptoms are common. It is worse in the overweight.
How can you repair a hiatal hernia?
At best, treatment of hiatal hernia is not very satisfactory although all sorts of ideas have been put forward.
Patients are advised to avoid stooping and bending as much as possible. This relieves the tendency for the stomach to slide up into the thorax, and lessens the chance of acid regurgitation, the main producer of symptoms.
In many cases, relief at night can be obtained by elevating the head of the bed by 23 cm (9 inches). This mechanically helps to keep the stomach where it belongs in the abdominal cavity.
However, many discover they tend to gravitate during sleep toward the foot of the bed. Also, it is essential either to sleep alone or get the spouse on the side and convince him it’s more comfortable sleeping in this strange fashion.
Avoiding food and drink that aggravates and meals or beverages that are too hot offers regular assistance.
Antacids have been used with varying success. It at least is a positive action, and this often helps psychologically. A product available called alginic acid (algin or alginate) is claimed to give specific relief to hiatal hernia symptoms. It is available under certain circumstances and so are most antacids.
In some cases, surgery has been advocated, but it is a major operation and most prefer to avoid such measures.
When to worry about hernia pain
A hernia is dangerous only if one of two things happens. If a piece of bowel which finds its way into the sac becomes “kinked” its blood supply may be cut off, and the bowel may decay and die. Or the bowel may become blocked, and obstruct the rest of the bowel.
Luckily neither of these things happens often, but if it does it must be treated without delay. The pain and discomfort which go along with such complications would warn you to send for your doctor immediately; so as long as you feel well you needn’t worry.
When is it time for hernia surgery?
A hernia can be cured by operation, and you would be wise to have this done if possible, because of those dangers already mentioned, as well as for your own comfort.
There is no reason to fear that you will be left with a weakness, or that the condition will recur after the operation. In young people, a simple operation, removal of the sac gives a complete cure.
If you have had a large hernia for many years, or the kind of rupture due to muscle weakness, the cure is not so simple, but that is the surgeon’s concern. After an efficient operation, the cure is usually complete, provided there has been sufficient tissue with which to make the repair.
Immediately after the operation healing takes place, and during this time you must be careful. Even then, though, some muscular activity is better than none, to prevent still more weakening of the muscles.
Most surgeons nowadays will encourage you to do some exercises, increasing gently, from the first day after your operation. After seven to ten days in bed, you will find yourself gradually returning to normal for the next three weeks.
By the time the month is up you will forget that you ever had an operation, still less a rupture, and you will be able to enjoy a normal active life, without taking any special precautions, although in older people or with large hernias of long duration where the tissues are thinned out and poorly developed, some care to avoid “straining” should be taken.
You can help yourself by trusting your surgeon and following his advice as best you can. Don’t be afraid to move and exercise if he tells you to. He knows his job and has done it well. The rest is up to you.
The continued use of a truss after the operation is not necessary except in very special circumstances when your surgeon definitely advises you to wear one.
Meanwhile, if you are waiting for admission to the hospital, or if for any reason an operation is inadvisable just at present, consult your doctor about what you should do to prevent things from getting worse.
If there is likely to be a long delay, he may advise you to wear a truss and will tell you where to get it made. This will prevent your hernia from getting any bigger. If no truss is worn, you must be careful to avoid violent muscular efforts and strain and to support the site of the hernia when you cough.