Medium Size Hiatal Hernia: Now What?

Medium Size Hiatal Hernia: Now What?

Anna from Houston sent us these questions:

  • I was diagnosed during an EGD/Upper Endoscopy with a “medium-sized” hiatal hernia, and I was wondering if I should have it repaired?
  • What causes hernias to get worse or bigger over time?
  • Is it best to closely monitor it and do surgery to repair it earlier rather than later, in order to prevent further complications or emergency medical attention?
  • Do “medium to larger hernias” need to be repaired?
  • What happens if you don’t repair a hiatal hernia?

Dear Anna,

The diaphragm or breathing muscle has a central opening, hiatus, through which the esophagus or food pipe goes through. Weakness in the lining covering this opening results in a hiatal hernia formation and upward movement of stomach into chest. There are different kinds of hiatal hernias. Prognosis and treatment depend on cause, anatomy, size, and associated symptoms.

At Houston Heartburn and Reflux Center, we divide hiatal hernias into two categories: sliding and paraesophageal hernias.

Sliding hiatal hernias are the most common (95% of all hiatal hernias). Sliding hiatal hernia is closely associated with acid reflux disease. Most patients with GERD have a sliding hiatal hernia. Sliding hiatal hernia repair and a concomitant Nissen fundoplication are indicated to control acid reflux disease. If left unrepaired, a symptomatic sliding hiatal hernia tends to get bigger with time resulting in a progressively weaker acid reflux barrier and worsening acid reflux symptoms. Acid reflux is the main cause of hiatal hernia development and growth. In the absence of acid reflux, there is no indication to repair an asymptomatic sliding hiatal hernia as it poses no risk of complications.

Paraesophageal hernias, on the other hand, are a completely different animal. Here, acid reflux does not play a role in the development of a paraesophageal hernia. Age, collagen synthesis genetic abnormalities, and an abnormally curved spine are some of the contributing factors to paraesophageal hernia development. Most patients have minimal symptoms that do not affect their quality of life. Some patients, however, report difficulty swallowing, pain, heartburn, nausea, vomiting and shortness of breath. Furthermore, ulcers may develop in the herniated stomach leading to blood loss and anemia. Finally, the herniated stomach may twist on itself leading to gastric volvulus and strangulation. Patients present with acute onset severe pain and inability to vomit. This is a surgical emergency requiring immediate medical attention and intervention.

Symptomatic paraesophageal hernias must be repaired. There is room to closely monitor an asymptomatic patient with a paraesophageal hernia. However, if surgical expertise is available and patient is a good surgical candidate with no contraindications for general anesthesia, elective repair is recommended.