Hiatal Hernia is one of the most misunderstood conditions in medicine. People blame this hernia for much more than it ever does. Patients with a hiatus hernia need to understand what it is and what might occur with it. Most importantly, they need to know it is unusual for serious problems to develop from this type of hernia.

The diaphragm is a sheet of muscle that separates th e lungs from the abdomen. When a person takes a deep breath, the dome-shaped diaphragm contracts and flattens. In doing this, the diaphragm pulls air into the lungs. The left diaphragm contains a small hole through which passes the tube-shaped esophagus that carries food and liquid to the stomach. Normally this hole called a hiatal, is small and fits snugly around the esophagus. The J-shaped stomach sits below the diaphragm.

In some people, the hiatus or hole in the diaphragm weakens and enlarges. It is not known why this occurs. It may be due to heredity, while in others it may be caused by obesity, exercises such as weightlifting, or straining at stool. Whatever the cause, a portion of the stomach herniates, or moves up, into the chest cavity through this enlarged hole. Hiatus hernia is very common, occurring in up to 60 percent of people by the age of 60.

1. Sliding Hiatus Hernia-- In this most common type of hiatus hernia, the herniated portion of the stomach slides back and forth, into and out of the chest. These hernia are normally small and usually cause no problems or even symptoms.
2. Fixed Hiatus Hernia-- In this case, the upper part of the stomach is caught up in the chest. Even with this hernia, there may be few symptoms. However, the potential for problems in the esophagus is increased.
3. Complicated or Serious Hiatal Hernia-- Fortunately, this type of hernia is uncommon. It includes a variety of patterns of herniation of the stomach, including cases in which the entire stomach moves up in the chest. There is a high likelihood that medical problems will occur with this hernia and that treatment, frequently involving surgery, will be required. Complicated hernias are uncommon.

In most patients, hiatal hernia causes no symptoms. This is especially true of sliding hernias. When symptoms occur, they may only be heartburn and regurgitation, when stomach acid refluxes back into the esophagus. Some patients with fixed hiatus hernias experience chronic reflux of acid into the esophagus, which may cause injury and bleeding. Anemia, or low red blood cell count, can result. Further, chronic inflammation of the lower esophagus may produce scarring and narrowing in this area. This, in turn makes swallowing difficult, and food does not pass easily into the stomach.

It is wrong to always blame a hiatal hernia for pain and indigestion. Hiatus hernias generally do not cause acute pain. This symptom may result form other disorders, such as peptic ulcers or even heart disease. Some patients with coronary heart disease fool themselves into believing their discomfort is due to a hiatus hernia. If upper-abdominal pain or indigestion occurs, people should not mislead themselves into thinking the cause is a hiatal hernia. Instead, the patient should seek medical advice.

Diagnosis of a hiatus hernia is typically made through an upper GI barium x-ray. A complementary test is gastroscopy, or upper-intestinal endoscopy, in which the physician visually examines the esophagus and stomach using a flexible scope while the patient is lightly sedated.

The complication of hiatal hernia are: Chronic heartburn and inflammation of the lower esophagus, called reflux esophagitis

• Anemia due to chronic bleeding from the lower esophagus.
• Scarring and narrowing of the lower esophagus causing difficulty in swallowing.
• While sleeping, stomach secretions can seep up the esophagus and into the lungs causing chronic cough, wheezing, and even pneumonia.

In addition, the complicated hernia can cause serious problems such as difficulty in breathing or sever chest pain, especially in the elderly.

Treatment is called for only when the hernia results in symptoms, such as persistent heartburn or difficulty in swallowing. Acid inflammation and ulceration of the lower esophagus also require treatment.

General guidelines for treating heartburn and esophagitis (inflammation of the esophagus) are:

• Avoid (or use only in moderation) foods and substances that increase reflux of acid into the esophagus, such as: nicotine, fatty foods, alcohol, caffeine chocolate, peppermint, spearmint
• Eat smaller, more frequent meals and do not eat within 2-3 hours of bedtime.
• Avoid bending, stooping, abdominal exercises, tight belts, and girdles all of which increase abdominal pressure and cause reflux.
• If overweight, lose weight. Obesity also increases abdominal pressure.
• Prescription medications. Certain drugs, such as intestinal antispasmodics, calcium channel blockers, and some antidepressants weaken the muscle strength of the lower esophagus.
• Elevate the head of the bed 8 to 10 inches by putting pillows or a wedge under the upper part of the mattress. Gravity then helps keep stomach acid out of the esophagus while sleeping.

• Drugs--Some medicines effectively reduce the secretion of stomach acid, while other increase the muscle strength of the lower esophagus, thereby reducing acid reflux.
• Surgery--The complicated hiatus hernia requires surgery occasionally on an emergency basis. Surgery otherwise is reserved for those patients with complications that cannot be handled with mediations. The mere presence of a hiatus hernia is not a reason for surgery.

A hiatal hernia is an extremely common condition which usually does not cause symptoms or problems. However, when it does, the physician can frequently treat the problem effectively with a well-planned program. Surgery is infrequently required to treat a hiatus hernia.