By Martha A. Simpson, D.O., M.B.A.
Assistant Professor of Family Medicine
Ohio University College of Osteopathic Medicine

HIATAL HERNIA TEST IS SIMPLE, PAINLESS BUT NOT “FLAVORFUL”

Question: I’m scheduled for a barium swallow next week to check and see if I have a hiatal hernia.  If the test confirms the diagnosis, the question will be whether or not I should have an operation to correct the problem.  Can you tell me what causes a hiatal hernia and the pros and cons of having an operation to correct the problem?

Answer: I think a brief review of anatomy will help you understand this condition. As you probably know, the chest is separated from the abdomen by a large, flat muscle called the diaphragm. The diaphragm must have an opening in it large enough to allow the esophagus to pass through to the stomach. It is a problem in these three parts -- esophagus, diaphragm and stomach -- that creates a hiatal hernia.

A hiatal hernia occurs when some or all of the stomach pushes up through the opening in the diaphragm, called the esophageal hiatus, into the chest.

We aren’t sure of the cause of a hiatal hernia. However, there are several factors that may contribute to having one: 1)an abnormally large esophageal hiatus; 2)a shortened esophagus due to old injury or inflammation; or 3) a loose attachment of the esophagus to the diaphragm.

There are two basic types of hiatal hernia. The most common one is a sliding hiatal hernia. Quite simply, a part of the stomach just slides up into the chest cavity. This can be a totally symptom-free disorder, or it can cause pain and heartburn -- producing a condition we doctors call gastro-esophageal reflux disease, or GERD. These GERD symptoms occur because a hiatal hernia can interfere with the proper function of the lower esophageal sphincter -- the muscle that “closes off” the stomach and keeps stomach acid in the stomach.

The sliding type of hiatal hernia is usually treated with symptomatic treatment. Overweight patients may be told to lose weight to decrease intraabdominal pressure. Some people elevate the head of the bed at night and avoid eating close to bedtime to keep the pressure of the stomach contents to a minimum. There is also medication for GERD symptoms.

The other major type, although very uncommon, is the paraesophageal, or diaphragmatic type of hiatal hernia. In this type, a part of the stomach protrudes up into the chest, while the junction of the esophagus remains properly fixed at the level of the diaphragm. The area of stomach protrusion does not slide back into the abdominal cavity. This type of hiatal hernia may be associated with chest pain but not GERD symptoms. It must be corrected surgically, since it can lead to a life-threatening strangulation of the hernia. The type of surgery would depend on the severity of your symptoms and the size of the hernia. If your tests show that you have the much more common sliding hernia, surgery is probably most appropriate in cases where medication cannot relieve GERD symptoms.

The best way to diagnose either type of hernia is with the upper GI test you are to have. It involves using X-rays and a wonderful tasting (ha!) barium drink that you swallow as a contrast medium. This simple and painless (but not flavorful) test makes it possible for the radiologist to see any abnormalities in your esophagus or stomach wall.

Family Medicine® is a weekly column. To submit questions, write to Martha A. Simpson, D.O., M.B.A., Ohio University College of Osteopathic Medicine, P.O. Box 110, Athens, Ohio 45701, or via e-mail to readerquestions@familymedicinenews.org. Medical information in this column is provided as an educational service only. It does not replace the judgment of your personal physician, who should be relied on to diagnose and recommend treatment for any medical conditions. Past columns are available online at www.familymedicinenews.org.