Do I Have a Hiatal Hernia?
What is the difference between a Hiatal Hernia and Gastroesophageal Reflux Disease, and Heartburn? Frequently I hear these terms used interchangeably. They are quite related but not the same. You can have one or two without the others. So what is the difference, and does that hiatal hernia matter?
The esophagus is the food pipe which transports food from mouth to stomach. Very simple organ. Just an elevator. One way, preferably except when we vomit or burp. The stomach is a pouch which sits in the abdomen (belly) and initiates the digestion process. There are five major functions of the stomach.
- Acid is created by the glands of the stomach to activate enzymes needed to breakdown proteins and absorb Vitamin B12.
- Digestive enzymes such as pepsin and trypsin begin the digestion of proteins.
- Food is churned into small particles.
- The resultant chyme can then be transported to the small intestine where absorption of nutrients takes place.
- Intrinsic Factor binds Vitamin B12 to allow absorption in the ileum of the small intestine
The short version is that when the stomach protrudes above the diaphragm into the chest, the upper stomach sits in the low pressures of the chest and gastric juices can come up back into the esophagus. The stomach sitting in the chest is the hiatal hernia, while the juices coming back up into the esophagus is called reflux. They are not the same, but they are related.
The Anatomy Revealed
If you don’t want the anatomy lesson, skip the next two paragraphs, but some will find it revealing. Let me paint you the picture now. The stomach sits in the abdomen below the diaphragm, and the esophagus (food tube) sits in the chest above the diaphragm. The diaphragm is always in motion coming down to expand the lungs and get in the air, and going up when you breath out. Everything above the diaphragm is considered the chest, and everything below is considered the belly or abdomen. Many of you speak of the stomach as if it was the entire abdomen, but in fact we have in our belly in addition to the stomach, a liver, spleen, pancreas, two kidneys, two adrenal glands on top of the kidneys, and major blood vessels including the abdominal aorta supplying blood to the organs and to the legs.
In the chest there is the heart with two lungs, on either side of the heart, the trachea or windpipe going to the lungs, and the esophagus. The esophagus sits behind the trachea and lower down behind the heart. Where the esophagus meets the stomach is called the esophagogastric junction (EG Junction). The muscles at the EG Junction create a high pressure zone to prevent the back flow of stomach contents into the esophagus. Too low pressure and stomach juices flow back up. Good if you are a dog and regurgitating food to nourish your young. Not so good if you are suffering from heartburn or cough. Too much pressure and swallowing is impaired. This happens in achalasia, a disease where the muscles fail to relax and food gets stuck. It also happens if surgery for reflux makes the flap too tight, and belching, vomiting, and swallowing are impaired.
A Little Too High
So in the ideal world, the esophagus stays in the chest and the stomach remains in the belly. Often the stomach gets pulled up into the chest creating a Hiatal Hernia. Stomach in the abdomen is what we want. Top of the stomach protruding into the low pressure zone of the chest creates a siphon bringing stomach acid and fluids up into the esophagus. The hiatal hernia is the portion of the stomach in the chest and the fluid coming up is called reflux. They are not the same but they are related.
So what’s the difference between heartburn and reflux? Many people with reflux do not suffer from heartburn. Many will suffer from cough or throat clearing. Some will get pneumonia or bronchitis from stomach contents going into the airway. Many will get sinus infections and recurring bronchial infections from the reflux going all the way to the sinus cavities. Heartburn may not be present or may be minor, and relieved by antacids. Antacids will not protect the airways and the respiratory tracts.
This kind of reflux affecting the airway is often called Silent Reflux because it does not have significant heartburn. I don’t like the term, because it is not so silent. Patients will cough or have throat clearing, wheezing, lump in the throat, and may have serious infections. Not very silent at all. Laryngopharyngeal Reflux (LPR), Airway reflux, Aerodigestive reflux are other terms that are more useful.
Fixing the Hiatal Hernia
Acid Blockers such as Proton Pump Inhibitors (PPI) and H2 Blockers (antihistamines), do not stop all the effects of reflux. They just stop acid. They do lessen symptoms of heartburn and chest pain, but many people are not satisfied with the relief they have on medication. That is because stomach contents reflux into the esophagus and airway but are less acidic than before. They continue to reflux up if the valve called the Lower Esophageal Sphincter is weak, or relaxes inappropriately. Reflux will continue when we overeat causing the stomach to be overly full pushing contents back up as when we overeat. Obesity and tight clothing will continue to cause reflux, even when it is less acidic.
Creating a tighter valve and reducing the hiatal hernia may correct reflux regardless of issues of acidity. This is called a fundoplication or a wrap. There are several versions of this operation. You can do open surgery, but since the late 1990’s advanced laparoscopic surgeons have performed the surgery laparoscopically, and this is now the standard. Only small incisions by the umbilicus (belly button) and upper abdomen are made and recovery is generally fast. Advanced endoscopists and surgeons have performed endoscopic incisionless fundoplication known as Esophyx TIF over the last several years with excellent control of reflux in the large majority of patients without need for incisions. TIF means Transoral Incisionless Fundoplication. That is, we do it through the mouth, with an endoscope, we make no cuts into the skin of the abdomen, and we wrap the upper stomach around the lower esophagus with tools attached to the scope from the inside of the stomach. In general, both laparoscopic surgery and Esophyx have been shown to have durable results with 80% being able to come off of medications for their reflux. That is not 100% but it is a lot for a relatively safe procedure where nothing is cut out. It is simply fantastic to be able to offer these solutions beyond what medications can achieve.
Photo By: Patrik Jones