How is hiatal hernia related to GERD?

You may have heard of GERD or gastroesophageal reflux disease, commonly associated with symptoms of heartburn that are commonplace in Singapore. You may also have seen that hiatal hernia, the protrusion of You may have heard of GERD or gastroesophageal reflux disease, commonly associated with symptoms of heartburn that are commonplace in Singapore. You may also have seen that hiatal hernia, the protrusion of the stomach into the diaphragm, can cause GERD and vice versa. If you are concerned about whether you have a hiatal hernia because of GERD symptoms, we’re here to help you gain a better understanding of the relationship between hiatal hernia and GERD so that you can seek timely treatment. 

What is hiatal hernia and its symptoms?

Hiatal hernia occurs when the stomach protrudes out through a hole in the diaphragm. The diaphragm has a small opening called the hiatus that the oesophagus passes through to connect to the stomach. When a hiatal hernia happens, the stomach bulges through the hiatus opening and into the chest area. 

It can happen to anyone at any age for any gender. It doesn’t always present with symptoms, but when present they are similar to those of GERD. 

Some symptoms of hiatal hernia include: 

  • Heartburn – burning sensation in the chest 
  • Regurgitation of food or liquids into the mouth 
  • Acid reflux from the stomach into the mouth through the oesophagus 
  • Difficulty swallowing
  • Chest or abdominal pain
  • Feeling full soon after eating 
  • Shortness of breath
  • Vomiting of blood or black stool, which may be due to gastrointestinal bleeding

A small hiatal hernia may not cause any problems at all. However, a large one may cause heartburn and acid reflux, and may even require surgery at times. 

What is GERD and its symptoms?

GERD is gastroesophageal reflux disease, a type of chronic acid reflux where the stomach acid often backflows from the stomach into your mouth through the oesophagus. 

This happens because the lower oesophageal sphincter at the connection between the oesophagus and stomach is weakened and relaxes when it shouldn’t, allowing the stomach contents to flow back up. One cause of this is a hiatal hernia where the stomach bulges into the diaphragm. Other things like obesity, pregnancy or medications can also cause GERD. 

The symptoms of GERD include: 

  • Heartburn – burning sensation in the chest 
  • Regurgitation of food or liquids into the mouth 
  • The feeling of food caught in your throat 
  • Coughing 
  • Chest pain 
  • Difficulty swallowing
  • Vomiting 
  • Sore throat and hoarseness 

How is hiatal hernia related to GERD?

GERD could arise as a result of hiatal hernia or hiatal hernia can be caused long-term GERD.

Clinical studies have shown that people with hiatal hernia are often more likely to have GERD. When there is a hiatal hernia, the hiatus opening enlarges which can facilitate acid reflux and aggravate GERD symptoms. It can lead to more serious effects such as obstruction of strangulation of the stomach. 

On the other hand, GERD leads to weakening of the sphincter which contributes to the development of hiatal hernia.

Can you have hiatal hernia without GERD and vice versa?

People can have a hiatal hernia without GERD, or they can have GERD without a hiatal hernia. However, for those who have both, it is often unclear which one caused which. 

If you have a hiatal hernia that shows more persistent and severe symptoms, it could indicate that you have both hiatal hernia and GERD. 

How do you diagnose hiatal hernia or GERD?

There are 3 major tests to diagnose hiatal hernia. 

X-ray 

You will have to drink a chalky liquid that coats the inside of the digestive tract, allowing us to see a silhouette of the oesophagus, stomach and upper intestine. 

Upper endoscopy 

In this procedure, we will insert an endoscope which is a thin, flexible tube that has a light and a camera down through your oesophagus into your stomach to check for inflammation. 

Oesophageal manometry 

This is a test that measures the coordination and force of the rhythmic muscle contractions by the oesophagus when swallowing and eating.

GERD can be diagnosed with the same methods as hiatal hernia as mentioned above. Another test that can be done for GERD is an ambulatory acid probe test, where a monitor is placed in the oesophagus to identify when and how long stomach acid is regurgitated. 

How do you prevent hiatal hernia?

There are a few lifestyle changes that you can make to prevent hiatal hernia. These include: 

  • Wearing loose clothing – to prevent pressure on the stomach 
  • Do not overeat – eat small frequent meals and eat slowly 
  • Do not smoke 
  • Lose weight – for those who are obese or overweight 
  • Avoid bending over or lying down with a full stomach – because doing so will increase pressure on the abdomen and cause heartburn 
  • Do not bend over or lie down 2 – 3 hours after eating 
  • Raise the head of the bed by about 6 – 8 inches – using wooden blocks or other sturdy objects but not pillows

What is the treatment for hiatal hernia? 

There are two main ways to treat hiatal hernia: medication and surgery. 

Medication

  • Antacids 

Antacids are used to neutralise stomach acid to provide quick relief from heartburns. Some examples are Mylanta, Rolaids and Tums. 

  • H2 Blockers (H2-Receptor Antagonists) 

These help to reduce the production of acid by the stomach. They include cimetidine, famotidine and nizatidine. Stronger versions may be prescribed by your doctor. 

  • Proton pump inhibitors

These are stronger acid blockers than the H-2 receptor blockers and allow the damaged oesophageal tissues to heal. Over-the-counter proton pump inhibitors examples are lansoprazole and omeprazole. Stronger versions of these can be prescribed by your doctor. 

Surgery 

Sometimes, hiatal hernia may require surgery, especially for those who have not seen improvements with medication or have complications like severe inflammation or narrowing of the oesophagus. 

A hiatal hernia may be treated with the Laparoscopic Fundoplication technique or Nissen Fundoplication, a minimally invasive surgery. It will be done with small incisions of less than an inch on the abdomen. It is used to wrap the upper part of the stomach around the lower oesophagus so as to tighten the sphincter around it, making acid reflux less likely to happen. The success rate of this surgery is high and recurrence is unlikely. 

Is hiatal hernia surgery painful? 

Hiatal hernia surgery is usually performed under general anaesthesia so you’ll be asleep during surgery. 

After surgery, you will be given medications to help with post-op pain. There might be pain or discomfort in the first few days, especially because of gas that enters the body during surgery. 

What is the recovery process like after hiatal hernia surgery? 

Following the surgery, you will be able to move around as per normal. However, you will need to refrain from strenuous or vigorous activities, such as lifting heavy objects. 

Additionally, you will have to be on a liquid diet for about 3 weeks before you are able to take solid foods again. 

Conclusion

If your acid reflux or heartburn symptoms are severe and affecting your quality of life, do visit your doctor. At G & L Surgical, we are able to provide you with Nissen Fundoplication surgery to help you with hiatal hernia. Or, your doctor may prescribe medication for you if your condition is less serious. You may also want to combine these treatment methods with lifestyle changes to prevent hiatal hernia from disrupting your life. With the right help, hiatal hernia is a condition that can be managed, treated and recovered from, so seek help early. 

References

  1. Kahrilas P. J. (1999). The role of hiatus hernia in GERD. The Yale journal of biology and medicine, 72(2-3), 101–111.
  2. Van Herwaarden, M. A., Samsom, M., & Smout, A. J. (2000). Excess gastroesophageal reflux in patients with hiatus hernia is caused by mechanisms other than transient LES relaxations. Gastroenterology, 119(6), 1439-1446.
  3. Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal Reflux Disease (GERD). Missouri medicine, 115(3), 214–218.
  4. Sfara, A., & Dumitrascu, D. L. (2019). The management of hiatal hernia: an update on diagnosis and treatment. Medicine and pharmacy reports, 92(4), 321–325. https://doi.org/10.15386/mpr-1323 

This article was written and medically reviewed by Dr. Ganesh Ramalingam, M.D.