Hernia, hiatus - Treating a hiatus hernia

Treatment for a hiatus hernia is usually only necessary if it's causing problems.

In most cases, people with a hiatus hernia only experience problems if the hernia causes gastro-oesophageal reflux disease (GORD). GORD can cause symptoms such as heartburn and an unpleasant taste in your mouth.

Lifestyle changes and medication are the preferred treatments, although surgery may be used as an alternative to long-term medication or if other treatments are ineffective.

Lifestyle changes

A number of self-care techniques may help relieve symptoms of GORD caused by a hiatus hernia. These include:

eating smaller, more frequent meals rather than three large meals a day
avoiding lying down (including going to bed) for at least three hours after eating or drinking
avoiding drinking during the night
removing certain foods from your diet if you think they make your symptoms worse
avoiding alcohol, caffeine, chocolate, tomatoes, fatty foods, spicy foods and acidic food or drinks (such as citrus fruit juice) if they make your symptoms worse
avoiding bending over or stooping, especially after eating or drinking
raising the head of your bed by around 20cm (8 inches) by placing a piece of wood or blocks under it – do not use extra pillows because this may increase pressure on your abdomen

If you are overweight, losing weight may help reduce the severity and frequency of your symptoms.

If you smoke, consider stopping. Tobacco smoke can irritate your digestive system and may make your symptoms worse.

Medication

A number of different medications can be used to treat symptoms of hiatus hernia. These are described below.

Antacids

Antacid medicines can relieve some of the symptoms of hiatus hernia. They come in liquid or tablet form and can be swallowed or chewed. They help neutralise stomach acid when they reach the oesophagus and stomach by making it less acidic.

However, antacid medicines don't work for everyone. They're not a long-term solution if symptoms persist or you are in extreme discomfort.

Antacids should not be taken at the same time as other medicines because they can stop other medicines from being properly absorbed by your body. They may also damage the special coating on some types of tablets. Ask your GP or pharmacist for advice.

Alginates

Alginates are an alternative medicine to antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.

H2-receptor antagonists

In some cases, a medicine known as an H2-receptor antagonist (H2RA) may be recommended if a hiatus hernia is causing GORD. Examples of H2RAs include cimetidine, famotidine and ranitidine.

H2RAs block the effects of the chemical histamine, which your body uses to produce stomach acid. H2RAs therefore help reduce the amount of acid in your stomach.

Side effects of H2RAs are uncommon. However, possible side effects may include diarrhoea, headaches, tiredness and a rash.

Some H2RAs are available over the counter at pharmacies. These types of HR2As are taken in a lower dosage than the ones available on prescription. Ask your GP or pharmacist if you are not sure whether these medicines are suitable for you.

Proton-pump inhibitors (PPIs)

Your GP may prescribe a medication called a proton-pump inhibitor (PPI). PPIs work by reducing the amount of acid produced by your stomach. Examples of the PPIs you may be prescribed include omeprazole, lansoprazole, rabeprazole and esomeprazole.

Most people tolerate PPI well and side effects are uncommon. When they do occur they are usually mild and may include headaches, diarrhoea, feeling sick, or constipation.

To minimise any side effects, your GP will prescribe the lowest possible dose of PPIs they think will be effective. You should let your GP know if the prescribed dose of PPIs doesn't work. A stronger dose may be needed.

Prokinetics

If your symptoms are not responding to other forms of treatment, your GP may prescribe a short-term dose of a prokinetic. Examples of prokinetic medicines include domperidone and metoclopramide.

Prokinetics speed up the emptying of your stomach, which means there is less opportunity for acid to irritate your oesophagus.

A small number of people who take prokinetics have what is known as extrapyramidal symptoms. Extrapyramidal symptoms are a series of related side effects that affect your nervous system and can include:

muscle spasms
problems opening your mouth fully
a tendency to stick your tongue out of your mouth
slurred speech
abnormal changes in body posture

If you have the above symptoms while taking prokinetics, stop taking them and contact your GP or out-of-hours doctor immediately. They may recommend you stop taking them. The symptoms should stop within 24 hours of the medicine being withdrawn.

Prokinetics are not usually recommended for people under the age of 20 because of an increased risk of extrapyramidal symptoms.

Surgery

Surgery is usually only recommended for a sliding hiatus hernia if the problem fails to respond to lifestyle changes and medication.

You may also wish to consider surgery if you have persistent and troublesome symptoms but do not want to take medication on a long-term basis.

Prior to surgery you may need further investigations to check how well the oesophagus moves (manometry) and how much acid is being refluxed (24-hour oesopageal pH studies).

Laparoscopic nissen fundoplication (LNF)

A procedure called a laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques used to treat GORD and sliding hiatus hernias.

LNF is a type of keyhole surgery that involves making a series of small cuts in your abdomen. Carbon dioxide gas is used to inflate your abdomen to give the surgeon room to work in.

During LNF, the stomach is put back into the correct position and the diaphragm around the lower part of the oesophagus is tightened. This should prevent any acid moving back out of your stomach.

LNF is carried out under general anaesthetic, so you will not feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.

After having LNF, most people can leave hospital once they have recovered from the effects of the general anaesthetic. This is usually within two to three days. Depending on the type of job you do, you should be able to return to work within three to six weeks.

For the first six weeks after surgery it is recommended you only eat soft food, such as mince, mashed potatoes or soup. Avoid eating hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.

Common side effects of LNF include difficulties swallowing (dysphagia), belching, bloating and flatulence.

These side effects should resolve over the course of a few months. However, in about 1 in 100 cases they can be persistent. In such circumstances, further corrective surgery may be required.

Para-oesophageal hiatus hernia

If you have a para-oesophageal hiatus hernia, where the stomach pushes up through the hole in the diaphragm next to the oesophagus, surgery may be recommended to reduce the risk of the hernia becoming strangulated.

See complications of hiatus hernia for more information.