“There is a debate about whether one condition causes another or if one is associated with the other,” says Jennifer Castro, MD, a general and laparoscopic surgeon at the Hampton VA Medical Center. ”People can have a hiatal hernia without GERD. And others can have GERD without a hiatal hernia. If they have both, it’s uncertain whether the hiatal hernia caused GERD.” According to the book, Hiatal Hernia Surgery, published in August 2017, suggests that the relationship between these conditions is relatively intertwined and has clinical significance. In fact, people with a hiatal hernia may be more likely to have GERD. There is also a close relationship between hiatal hernia size and incidence of GERD. Leslie Memsic, MD, a surgical oncologist who specializes in breast cancer and hernia treatment at the Bedford Breast Center in Beverly Hills, says some studies suggest that chronic acid reflux actually leads to weakening of the sphincter and the development of a hiatal hernia. “But, more commonly, a large hiatal hernia is thought to contribute to GERD,” Dr. Memsic says.
Is It a Hiatal Hernia, GERD, or Both?
A hiatal hernia can occur from long-lasting GERD or GERD could be a symptom of a hiatal hernia, according to the Cleveland Clinic. When GERD progresses, it can cause the lower esophageal sphincter to lose its function, which may cause a hiatal hernia, according to RefluxMD. A hiatal hernia could also worsen GERD symptoms. So the bottom line is, you could have one of these conditions or they can coexist. Here’s how you can differentiate the two: A hiatal hernia occurs when the hole in the diaphragm (hiatus) through which food and liquids pass from the esophagus into the stomach enlarges. This facilitates acid reflux and can cause the stomach to slide upward into the chest, says Dr. Castro. This condition in severe cases can lead to more serious complications such as obstruction or strangulation of the stomach, says Memsic. What could put you at risk? Weakened muscles in the diaphragm can allow the stomach to move freely into the hiatus, or inherited structural abnormalities in the diaphragm can cause a congenital hiatal hernia, which presents at birth. Other causes include excess pressure on the abdomen or muscle strain due to heavy coughing, constipation, or intense physical exertion. Pregnancy and obesity are also risk factors for hiatal hernia, according to the Mayo Clinic. GERD is very common and typically presents as heartburn, a condition that affects more than 40 percent of Americans. GERD occurs when “stomach contents reflux back into the esophagus, causing issues such as heartburn, regurgitation, difficulty swallowing. And even chest pain is the presence of stomach contents in the esophagus,” says Castro. RELATED: What’s the Difference Between Acid Reflux and GERD? Small hiatal hernias don’t typically present signs or symptoms, according to the Mayo Clinic, but those with a more severe hernia may experience:
HeartburnRegurgitation of food or liquids into the mouthBackflow of stomach acid into the esophagus (acid reflux)Difficulty swallowingChest or abdominal painShortness of breathVomiting of blood or passing of black stools, which may indicate gastrointestinal bleeding
In serious cases, a hiatal hernia can cause bleeding, strangulation, and perforation of the stomach, says Castro. Symptoms of GERD, according to the Mayo Clinic, include:
A burning sensation in your chest (heartburn), usually after eating, which might be worse at nightChest painDifficulty swallowingRegurgitation of food or sour liquidSensation of a lump in your throat
According to the Cleveland Clinic, many people actually have a hiatal hernia without having GERD and others have GERD without having a hiatal hernia. Most people with a hiatal hernia don’t have any symptoms. If you have a hiatal hernia that presents with frequent and more severe symptoms, this could be an indicator that you have both conditions (hiatal hernia and GERD), according to an article published by the University of Wisconsin’s School of Medicine and Public Health.
How to Diagnose a Hiatal Hernia and GERD
There are three major tests to diagnose a hiatal hernia, according to the Mayo Clinic. Like a hiatal hernia, GERD can be diagnosed by performing an upper endoscopy, an esophageal manometry, or an X-ray of your upper digestive system, according to the Mayo Clinic. Patients can also be diagnosed with GERD through an ambulatory acid (pH) probe test, in which a monitor is placed in your esophagus to identify when and how long stomach acid regurgitates there.
Medical Treatment and Surgical Options to Deal With Hiatal Hernia and GERD
“The majority of patients with hiatal hernia that have symptoms of GERD can be managed by lifestyle changes and medication,” says Memsic, adding that less than 20 percent of patients with hiatal hernia will require surgery due to risk of strangulation, obstruction, or perforation. “For straightforward GERD symptoms, lifestyle modification and medicines like the proton pump inhibitors [PPIs] are the mainstays of treatment. We also recommend avoiding heavy meals, to remain upright for at least three hours after eating, and to elevate the head of the bed to prevent reflux while sleeping,” says Castro. Patients with GERD should also avoid food and drink that can increase reflux such as coffee, chocolate, carbonated beverages, alcohol, citrus and acidic foods, onions, mint, fatty foods, spicy foods, and garlic, says Castro. Foods such as yogurt, ginger, and aloe vera can help to soothe the stomach, says Memsic. A symptomatic hiatal hernia can be treated with lifestyle changes, dietary changes, and medication, including antacids, H2 blockers, and proton pump inhibitors. It is important for proton pump inhibitors to be given under the care of a physician, as they can interfere with calcium and aggravate cardiac issues, says Memsic. Patients with more severe hiatal hernia and GERD symptoms may need surgery. Laparoscopic (minimally invasive) repair of a hiatal hernia and GERD, called Nissen fundoplication, is considered to be 90 percent effective in most patient populations, according to the Cleveland Clinic. The surgery strengthens the lower esophageal sphincter and requires general anesthesia and a one-day stay in the hospital. After the operation, patients will no longer need to take antacid medication. Patients who have persisting symptoms that don’t improve after implementing lifestyle changes and taking medical treatment should consult a doctor, says Memsic, adding that surgery should be a last resort.
