Unlock the Truth: Hiatal Hernia, Weight Loss, and Bariatric Surgery Secrets Revealed!

A hiatal hernia is a condition where part of the stomach pushes up through the diaphragm, the muscle wall separating the chest and abdomen. While many people with hiatal hernias experience no symptoms, others may suffer from heartburn, acid reflux, and other related issues. This article explores the connection between hiatal hernias, weight loss, and bariatric surgery, providing a comprehensive overview for those seeking information and potential solutions.

Understanding Hiatal Hernias

A hernia is a hole, tear, or other type of damage in a muscular structure that results in the bulging out of underlying tissue. Hiatal hernias occur in the esophagus when a portion of the stomach pushes up through the diaphragm, the muscle wall in the abdominal cavity. Some people develop hiatal hernias but never experience symptoms. Others can develop numerous issues, including:

Heartburn
Acid reflux
Difficulty swallowing
Chest pain
Trouble breathing
Feelings of fullness while eating

People who are obese or over the age of 50 are most at risk for developing this type of hernia. However, it can also result from an injury, heavy lifting, underlying health conditions, or muscular changes to the diaphragm. Some people may be genetically predisposed to the condition because they have a larger-than-normal opening in the diaphragm, known as the hiatus, where the esophagus passes through.

Types of Hiatal Hernias

There are two main types of hiatal hernias:

Sliding Hiatal Hernia: This is the most common type, where the stomach and the esophagus slide up into the chest through the hiatus. Many people with sliding hiatal hernias don't experience any symptoms and probably won’t feel the hernia itself. Unlike other kinds of hernias, you probably won’t see the bulge from the outside, either.
Paraesophageal Hiatal Hernia: This type is less common and more likely to cause complications. In a paraesophageal hernia, the esophagus and stomach stay in their normal locations, but part of the stomach squeezes through the hiatus next to the esophagus. This type may be related to obesity or other factors.

Symptoms of Hiatal Hernia

Many people never have symptoms of hiatal hernias. But among those who do, the most common symptoms are related to chronic acid reflux (gastroesophageal reflux disease, or GERD). These include:

Heartburn: A burning sensation in your chest, especially after eating.
Noncardiac chest pain: Recurring chest pain that feels like angina, but isn’t.
Indigestion: Feeling full soon after eating, with a burning type of abdominal pain.
Burping and regurgitation: Food, gas and acid rising back into your throat.
Difficulty swallowing or a lump in your throat when you swallow.
Sore throat and hoarseness when you speak, due to irritation from the acid.

Not everyone with a hiatal hernia has acid reflux, and not everyone with acid reflux has a hiatal hernia. But if you’ve recently begun to notice these symptoms more often, they might be related.

Other possible warning signs of a hiatal hernia might include:

Nausea, due to compression of your stomach or acid overflow, or both.
Shortness of breath, if your hernia is compressing your lungs.
Pressure or pain in your upper abdomen or your lower chest.

These symptoms are more likely with larger paraesophageal hernias.

What is Hiatal Hernia Pain Like?

Your hiatal hernia is located at the junction between your abdomen and your chest. If you feel pain from the hernia itself, it might feel like chest pain or abdominal pain. You might feel a hiatal hernia if it gets compressed or pinched during certain activities or positions. For example, bending over, coughing or lifting something heavy might affect a larger hiatal hernia. Pain might be a sign that it’s getting worse.

Most of the time, pain from a hiatal hernia is related to acid reflux rather than the hernia itself. Acid irritates your esophagus, which runs through your chest up to your throat. You may feel it higher or lower, or the pain may radiate throughout your chest. It may burn. For some people, it may even feel like a heart attack. If you’re in doubt, it’s always best to have chest pain checked out by a healthcare provider.

Read also: Hiatal Hernia and Diet

How Does a Hiatal Hernia Cause Acid Reflux?

When the gastroesophageal junction - the place where your esophagus meets your stomach - rises above your diaphragm, it pulls some of the muscles that would normally contract to prevent acid reflux. When these muscles can’t tighten enough to close your esophagus effectively, stomach acid can wash back into it. The hernia also traps a pocket of acid at the top of your stomach that can’t clear away.

What Causes a Hiatal Hernia?

A hernia becomes possible when there’s a weak spot in the tissues that separate your different body compartments. That weak spot creates an opening for a hernia to come through. A hiatal hernia, in particular, comes through an opening that already exists: the esophageal hiatus, where your esophagus passes through your diaphragm. This opening only has to widen a little to make a hiatal hernia possible.

Sometimes a specific injury, surgery or even a birth defect causes the original weakness that creates a hernia. But more often, it’s cumulative damage from years of daily stress and strain. Anything that produces extra pressure in your abdominal cavity can wear on your diaphragm over time. Some of the most common forces that create abdominal pressure and contribute to hiatal hernias include:

Chronic coughing or sneezing.
Chronic straining to poop (constipation).
Chronic obesity (BMI, or body mass index, greater than 30).
Frequent vomiting.
Intense exercise or heavy lifting.
Pregnancy and childbirth.

How Serious is a Hiatal Hernia?

Most aren’t serious. Most don’t even cause symptoms. You may never know that you have one. But a larger hernia could eventually become serious. You’d probably have symptoms if you had a larger one.

What are the Possible Complications of a Hiatal Hernia?

The most common problem that hiatal hernias cause is chronic acid reflux. Chronic acid reflux can do damage to your esophagus over time, if it’s severe and medications don’t manage it well enough.

Complications of chronic acid reflux can include:

Esophagitis: Acid in your esophagus causes inflammation of your esophagus lining. Chronic inflammation can cause pain, swallowing problems, ulcers and even bleeding.
Esophageal stricture. Chronic inflammation can cause scarring of your esophagus tissues. Scar tissue can interfere with your swallowing muscles and cause your esophagus to narrow.
Barrett’s esophagus. Chronic inflammation can also eventually lead to tissue changes called Barrett’s esophagus. This condition isn’t harmful by itself, but it’s considered precancerous.

More rarely, a hiatal hernia may cause complications if it gets stuck or compressed in the hiatus. This usually only happens with the less common types of hiatal hernias. Complications could include:

Gastrointestinal obstruction. Your stomach or another organ could get stuck and compressed or twisted in the hiatus, creating a blockage in your gastrointestinal tract.
Gastritis. Trapped acid in the herniated part of your stomach could cause inflammation, stomach ulcers and bleeding inside.
Ischemia. Your hernia could become so tightly compressed that it cuts off its own blood supply.

Diagnosis of Hiatal Hernia

A hiatal hernia is often discovered during a test or procedure to determine the cause of heartburn or pain in the chest or upper abdomen. These tests may include:

X-ray of your upper digestive system: X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract.
Endoscopy: Endoscopy is a procedure to examine your digestive system with a long, thin tube with a tiny camera, called an endoscope. A procedure to look at the esophagus and stomach, called an endoscopy.
Esophageal manometry: A test to measure muscle contractions of the esophagus, called an esophageal manometry. This test measures the rhythmic muscle contractions in your esophagus when you swallow.

Hiatal Hernia and Weight Loss

Doctors often recommend a plan to safely shed extra pounds to overweight hiatal hernia patients. This is true both before and after surgery.

Pre-Surgery Weight Loss

Because surgery is a last resort for any condition, it’s important to try other less invasive interventions first. For those who are obese, weight loss can significantly improve and even resolve hiatal hernias altogether. Without the extra pressure from fatty tissue surrounding the stomach, the digestive system can rest naturally in place and function more efficiently. The result is often a reduction in painful symptoms.

Even if weight loss alone is not enough to manage hiatal hernia symptoms, your doctor may still recommend it if you are overweight. Not only can it improve your overall health, but it can help reduce your risks of developing another hiatal hernia in the future.

However, rapid weight loss is rarely safe or recommended. Instead, make gradual healthy changes that result in slow and steady weight loss, according to your doctor’s recommendations. This approach yields more lasting results without causing unnecessary harm.

Post-Surgery Weight Loss

The body’s response to surgery, an expected loss of appetite, and dietary restrictions can all lead to weight loss after hiatal hernia surgery. Dropping a few pounds over the course of a few weeks is normal for most patients. Most people can expect to gain this back within the next few months as more normal eating habits resume.

If your stomach lost any of its capacity during the procedure, you may lose weight and keep it off. Some patients have hiatal hernia repairs and bariatric surgery simultaneously. This combination of procedures can lead to continued weight loss over time.

While all of these situations are normal, rapid weight loss after surgery is not. If you find yourself losing more than two pounds per week, talk with your doctor.

Bariatric Surgery and Hiatal Hernia

People considering weight loss surgery often ask, “Can I have bariatric surgery with a hiatal hernia?” The short answer is yes.

Bariatric surgery helps patients lose weight if other efforts, like changes to diet and exercise habits, haven’t been successful. Bariatric surgery can reduce or eliminate a hiatal hernia even when the surgeon doesn’t actively address it. Consequently, your doctor may recommend that you have a hiatal hernia repair (HHR) at the same time as your bariatric surgery.

Hiatal Hernia Repair During Bariatric Surgery

If you’re considering bariatric surgery and also experiencing heartburn and pain in your chest or upper abdomen, your doctor may want to determine whether you have a hiatal hernia.

Bariatric surgery and hiatal hernia repair can help you lose weight and eliminate GERD symptoms.

Surgical Options for Hiatal Hernia Repair

Sometimes a hiatal hernia requires surgery. Surgery may help people who aren't helped by medicines to relieve heartburn and acid reflux.

Surgery to repair a hiatal hernia may involve:

Pulling the stomach down into the abdomen
Making the opening in the diaphragm smaller
Reshaping the muscles of the lower esophagus. This helps keep the contents of the stomach from coming back up.

Surgery may be performed using:

A single incision in the chest wall, called a thoracotomy.
A technique called laparoscopy. In laparoscopic surgery, a surgeon inserts a tiny camera and special tools through several small incisions in the abdomen.

Surgeons can repair hiatal hernias in one of two ways: traditional open surgery and robotic-assisted laparoscopic surgery. Both are effective options, with laparoscopic alternatives posing fewer risks and faster recovery times for patients. However, the severity of the case determines which route your surgeon takes.

In most patients, the surgeon simply pushes the stomach tissues back below the diaphragm and then takes steps to prevent bulging from reoccurring. Others may require more extensive repairs, including the reconstruction and repair of a damaged esophagus.

Lifestyle and Home Remedies

Making a few lifestyle changes may help control the symptoms caused by a hiatal hernia.

Don't eat foods that trigger heartburn.

Tips for Safe and Healthy Surgery Recovery

In addition to weight loss after hiatal hernia surgery, you can also expect a few other side effects, including:

Difficulty swallowing, which should improve with healing
Discomfort at the surgical site
Abdominal bloating
Nausea

To minimize or prevent these issues, follow your doctor’s instructions for home care. Avoid foods and beverages that can irritate the stomach and contribute to gas or heartburn, such as alcohol, acidic foods and beverages, fried foods, and cruciferous vegetables. Also, do not drink with a straw, as this forces more air into the digestive tract.

In addition, keep all incision sites properly cleaned and bandaged. Avoid intense activity or heavy lifting, but stay mobile by walking as soon as you are able; this helps minimize the risks of post-surgical blood clots. Your doctor may also recommend breathing or coughing exercises to restrengthen your diaphragm.

A Rare Case: Hernia Through the Foramen of Morgagni

First described in 1761 by Giovanni Morgagni, 1682-1771, Professor of Anatomy, Padua, Italy,1 hernia through the foramen of Morgagni is an anteriorly manifesting hernia arising from a defect between the septum transversum and the costal attachments of the diaphragm. It is the rarest form of diaphragmatic hernia, accounting for less than 1% of surgically treated diaphragmatic hernias.

A 41-year-old Hispanic man was referred for gastroenterologic evaluation after 3 weeks of postprandial epigastric pain with nonprojectile emesis. The pain occurred approximately 5 minutes after ingesting food and was dull in character, nonradiating, and relieved by vomiting. His primary care physician had treated his pain with proton pump inhibitors, with no symptom improvement. His bowel motion was unchanged at 4 times per week, and there was no progressive increase in abdominal girth or dyspnea. The patient had no history of coronary or peripheral atherosclerosis, connective tissue disorder, or chronic remittent epigastric pain. He had not undergone any surgical procedure, and there were no symptoms of hyperthyroidism.

Physical examination revealed a 5′6″, 120-pound asthenic male in no distress. His blood pressure was 110/60 mm Hg; his pulse was 78 bpm regular, and respiratory rate was 20/min. Conjunctiva was pink, sclera was anicteric, there was no adenopathy, and oral mucosa was moist with good skin turgor. His abdomen was scaphoid with no surgical scars, no visible peristaltic wave, no succussion splash, no bruit, no palpable mass, and bowel sounds were normal.

Esophagogastroduodenoscopy showed an hourglass distortion of the stomach due to a midgastric corpus extrinsic compression with occlusion of more than 95% of the gastric lumen and gastric folds converging to the point of constriction; no mass or mucosal ulceration was noted. Upper gastrointestinal series: barium retained in proximal stomach with reflux due to midgastric obstruction.

The patient underwent exploratory laparotomy; a diaphragmatic hernia of Morgagni containing the stomach, which was constricted in the middle, was found, as well as a loop of the transverse colon. The hernia contents were not spontaneously reducible due to fibrosis and scarring at the base of the hernia. Adhesions were lysed and the hernia contents reduced into the abdominal cavity, with repair by suturing of the foramen of Morgagni. There was no associated paraesophageal hernia.

This case demonstrates the clinical course of a patient with incomplete gastric obstruction due to herniation through the foramen of Morgagni. Typically, postprandial epigastric pain with significant weight loss is due to chronic mesenteric ischemia, gastric ulcer, or gastric malignancy.1 Herniation of the stomach through the foramen of Morgagni is uncommon2 and is not a well-characterized cause of this clinical presentation. Ninety percent of hernia cases of the foramen of Morgagni occur on the right side of the diaphragm, as the left side of the diaphragm is enhanced by the heart and pericardium. In adults, the pathology is seen more in women and individuals over age 50. Transverse colon is the most common viscus herniating through the foramen. Other intra-abdominal structures described as herniating through the foramen include the greater omentum and the liver.3,6-10 Abdominal symptoms predominate in obese patients and nonobese patients tend to have respiratory symptoms.

Once diagnosis is confirmed, surgical correction is mandatory. Laparoscopic or open transabdominal or transthoracic repair have been described. Excision of the hernia sac is optional; leaving it behind is believed to reduce pleural and pericardial injury and prevent escape of carbon dioxide into the thorax.2,3,7,9 Direct interrupted or running suture repair can be used for small defects.

Treatment

Most people with a hiatal hernia don't experience any symptoms and won't need treatment.

Antacids that neutralize stomach acid. Antacids may provide quick relief.
Medicines to reduce acid production. These medicines are known as H-2-receptor blockers. They include cimetidine (Tagamet HB), famotidine (Pepcid AC) and nizatidine (Axid AR).
Medicines that block acid production and heal the esophagus. These medicines are known as proton pump inhibitors. They are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Proton pump inhibitors available without a prescription include lansoprazole (Prevacid 24HR) and omeprazole (Prilosec, Zegerid).

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