Many older adults don’t find out they have a hiatal hernia until they have a CT scan for another reason. Because many cases are asymptomatic – or misdiagnosed – the news comes as an unwelcome surprise.
Asa Ramdath, MD, a surgeon at Cleveland Clinic Tradition Hospital, explains that the diaphragm, located just under the rib cage, is a broad, flexible, muscular plate that separates the torso’s two main sections – the chest cavity and abdominal cavity.
“The diaphragm has an opening called the hiatus, through which the esophagus passes before connecting to the stomach. Sometimes the upper portion of the stomach pushes through the hiatal opening and into the chest cavity. This is called a hiatal hernia,” Dr. Ramdath says.
Dr. Ramdath adds that if you’re looking for the number of people who have a hiatal hernia, be prepared to find varying statistics. “The range is as low as 10 percent to as high as 60 percent. That’s primarily because so many people have asymptomatic cases that aren’t counted,” he says.
“One thing that’s certain is that numbers are increasing. Onset usually occurs in people over age 50, and as more of the population ages, more cases are diagnosed.”
Cleveland Clinic estimates that in the U.S., about 50 percent of those over the age of 50, 60 percent over the age of 60, and 70 percent over the age of 70 have the condition.
There are four types of hiatal hernia. Mayo Clinic outlines them:
- Type 1: The most common type – which includes about 95 percent of cases – where the gastroesophageal junction (the place where the esophagus meets the stomach) slides up into the chest through the diaphragm’s opening. Dr. Ramdath says it occurs because the diaphragm is no longer “snug.”
- Type 2: A portion of the stomach bulges up next to the esophagus, but the junction stays put.
- Type 3: Combines features of both Type 1 and Type 2 hernias, with both the GE junction and part of the stomach moving up. Dr. Ramdath says the severity of this type of hiatal hernia can vary widely from patient to patient.
- Type 4: The most complex and problematic, where the stomach and another abdominal organ (like the colon, small bowel, or spleen) push into the chest through the hiatus.
Dr. Ramdath says that symptoms vary from patient to patient, with some experiencing none. “The most common complaints we hear are acid reflux, GERD, heartburn, sour taste in the mouth, nausea and vomiting.
“More serious side effects include adult-onset asthma, weight loss and anemia.”
Cedars-Sinai Medical Center adds additional symptoms, including trouble swallowing, feeling full after eating only a small amount of food, belly or chest pain and abdominal bleeding.
Although aging is the most prevalent risk factor, Dr. Ramdath lists others that can affect your chance of getting a hiatal hernia.
- Obesity.
- Multiple pregnancies.
- Smoking, chronic coughing, COPD.
- Chronic constipation and straining to move your bowels.
- Straining to pass urine.
Johns Hopkins University adds the following:
- Being born with an unusually large hiatus.
- Injury or trauma to the area such as force from a seatbelt during an accident.
- Persistent and intense pressure on the surrounding muscles caused by lifting heavy objects.
Symptoms range from none in asymptomatic cases to severe and even life-threatening is the most serious cases.
Treatment varies by type and severity of the patient’s hiatal hernia, says Dr. Ramdath. “If you have a less severe case, there are a lot of great options to treat your reflux symptoms, either over the counter or by prescription.
“You can also try such lifestyle changes as losing weight if you’re obese, quitting smoking, not eating close to bedtime, and eliminating foods that cause you discomfort,” he says.
“If this is taking care of your discomfort and allows you to have a good quality of life, you can probably say no to surgery. However, if it doesn’t work you need to talk with your doctor and see if surgery is recommended.
There are three primary surgical options – open, laparoscopic and robotic. The appropriate type of surgery for you will depend on the size, severity and location of your hernia. Your medical team will determine which is right for you.
- Open: The traditional method for hernia repair, it is an open surgical procedure with an incision in the abdomen above the hernia.
- Laparoscopic: A minimally invasive technique, in which your surgeon will make several small, half-inch incisions. Through one “keyhole,” the doctor will insert a thin tube with a video camera attached. Repairs will be made through the other incisions, using miniature instruments that are guided by the camera.
- Robotic: Similar to a laparoscopic repair, a robotic hernia repair is a minimally invasive surgery requiring small incisions where the surgeon controls the procedure from a specialized robotic console. Patients may experience a faster recovery following robotic surgery compared to an open surgery.
Dr. Ramdath says that surgery is well tolerated and has a track record of minimal complications. “Not everyone needs to have surgery, but a hiatal hernia needs to be discussed with your doctor. You need to stay aware of your condition,” he says. “Hernias don’t get better with time.”
Asa Ramdath, MD, is a surgeon who practices at Cleveland Clinic Tradition Hospital. He completed his medical education at the University of the West Indies, did his internship and residency at Howard University Hospital and completed a fellowship at Cleveland Clinic, Florida. He is board certified in general surgery. His office is located at Tradition HealthPark Two,10080 Southwest Innovation Way, Port St Lucie. Call 877-463-2010 for an appointment.
