How a Hiatal Hernia Is Treated

For most people, hiatal hernias will cause only mild, intermittent heartburn that can be easily treated with antacids and acid-blockers. Unless the hernia is especially large, over-the-counter (OTC) medications, weight loss, and dietary changes are usually enough to ensure relief. In more severe cases, though, surgery may be needed if the herniation is causing obstruction or cutting off the blood supply. Depending on the severity of the complication, open or laparoscopic ("keyhole") surgery may be used to repair the damage.

Symptoms of a hiatal hernia are typically related to the dysfunction of the lower esophageal sphincter (LES), which separates the stomach from the feeding tube (esophagus). Because a hernia can alter the position of the LES, stomach acid and food can sometimes reflux into the esophagus and cause inflammation and discomfort.

This happens most commonly in people who are overweight or obese. In addition to placing excessive stress on the stomach and upper abdomen wall, obesity promotes reflux by interfering with the normal flow of digestion. Moreover, the foods consumed in a typical, high-fat diet are more likely to stimulate acid in order to break down the excess fats and simple carbohydrates.

To overcome this, you need to address the underlying causes of reflux. There are several key lifestyle changes that can help:

• Weight loss relieves the abdominal pressure that promotes herniation. While it won’t necessarily reverse a hernia, it may prevent a mild hernia from developing into a more serious paraesophageal hernia. This is the type associated with an increased risk of gastroesophageal reflux disease (GERD).
• A low-fat, high-fiber diet not only contributes to weight loss, it can help normalize bowel function and relieve constipation that contributes to herniation. High-fiber foods are an effective means of relief.
• Proper hydration, namely drinking no less than eight glasses of water per day, can further reduce the risk of constipation while diluting concentrations of acid in the stomach.
• Avoiding trigger foods can provide relief whatever your age or weight. Common triggers include red meat, fried foods, spicy foods, whole-fat dairy, tomato-based sauces, citrus, carbonated drinks, caffeine, alcohol, and excessive salt. By contrast, "safe" foods such as lean chicken, fish, low-fat dairy, grains, and vegetables can help treat reflux symptoms.

OTC medications are the first-line defense for treating acute attacks of heartburn and acid reflux. These can be helpful in reducing symptoms as you work on addressing their root cause, the reflux itself, with the above modifications. These drugs are considered safe for intermittent use but may cause problems if used in excess.

Among some of the more commonly used medications:

• Antacids, like Tums, Rolaids, and Gaviscon, work by neutralizing stomach acid with ingredients such as aluminum hydroxide and magnesium hydroxide. Overuse can lead to constipation (magnesium-based antacids) and diarrhea (aluminum-based antacids). 
• H2 receptor blockers, which reduce the production of stomach acids, include such popular OTC brands as Pepcid (famotidine), Tagamet (cimetidine), and Zantac (ranitidine). Side effects include constipation, diarrhea, dry mouth, headaches, and ringing in the ears (tinnitus).
• Proton pump inhibitors (PPIs) offer similar action to H2 blockers but are stronger and faster. They include Nexium (esomeprazole), Prevacid (lansoprazole), and Prilosec (omeprazole). PPIs are more typically used if an H2 blocker fails to provide relief. Headache, constipation, diarrhea, and flatulence are common side effects.

Stronger versions of H2 blockers and PPIs are available by prescription.

Surgery for a hiatal hernia is only indicated if a paraesophageal hernia is causing symptoms that cannot be treated with medications or lifestyle changes. This is because the appearance of symptoms reveals that the stomach has bulged further into the chest cavity and is now altering the position of the LES. As a paraesophageal hernia tends to be progressive, it is far better to treat it earlier than later.

Some of the more severe complications, such as volvulus (a condition where the stomach twists more than 180 degrees) and strangulation (where blood circulation is cut off), are considered medical emergencies.

If you have a large hernia, the choice of surgery will largely be determined by the nature and severity of the complication.

Open or Laparoscopic Repair

Either a transthoracic ("open") or transabdominal (laparoscopic, or "keyhole") surgery may be used to repair a paraesophageal hernia.

• Open surgery involves entry into the body through an incision, usually on the left side of the body. It is more commonly used in emergency situations where there is severe bleeding or an organ rupture. It may also be used in non-emergency situations, such as when the entire stomach has slipped into the chest cavity (known as an intrathoracic stomach).
• Laparoscopic surgery involves the insertion of multiple surgical instruments into three more keyhole-sized incisions in the abdomen. For non-emergency situations, it is considered just as effective as a transthoracic surgery but with far fewer complications and a quicker recovery time.

Nissen Fundoplication

Nissen fundoplication is newer technique performed laparoscopically. The aim of the surgery is to tightly wrap the upper part of the stomach (called the fundus) around the esophagus and secure it in place with stitches or staples so that it's held upright and supported. If performed correctly, fundoplication can realign the LES into a position where it functions normally.

Nissen fundoplication is considered extremely safe and effective, with a less than 1 percent risk of mortality and an efficacy rate of 89.5 percent over 10 years. Bloating, vomiting, and irritable bowel syndrome (IBS) are common post-operative side effects that tend to resolve on their own within two to four weeks.

In addition to antacids and acid-blockers, there are a number of complementary therapies that may provide significant relief of acute symptoms.

Licorice

Licorice, derived from the licorice root, has long been used to treat heartburn and other gastrointestinal symptoms. While research remains lacking, some studies have suggested that it has its place alongside traditional acid-blocking medications.

A 2013 study published in Clinical and Experimental Gastroenterology reported that the combined use of a licorice root extract and a prescription-strength PPI (pantoprazole) resulted in fewer symptoms of heartburn, chest pain, and abdominal swelling compared to using a PPI alone.

Licorice tea is one of the more common forms used. Another, known as deglycyrrhizinated licorice (DGL), is available as a nutritional supplement and may be more tolerable due to the removal of glycyrrhizin (a substance known to lower blood potassium levels).

Ginger

Ginger is another popular option that may help alleviate heartburn symptoms. Ginger root is rich in antioxidants and contains phenolic compounds believed to reduce gastric contractions and, thus, lessen the likelihood of acid reflux.

However, if used in excess, ginger may have the opposite effect. A 2014 study from Stanford University reported that, while ginger extract or powder form may relieve spasms and improve gastrointestinal motility, daily doses of higher than five grams could actually increase the risk of heartburn and abdominal discomfort.

Ginger can be purchased as a tea or in powder, capsule, or liquid formulations.

As with any CAM options, it's best to discuss licorice and ginger with your doctor before trying them.