Acid Reflux? Could it be a Hiatal Hernia
To Summarize:
- GERD may be known as acid reflux, but it's not due to too much acid
- In fact, treatment for GERD should not involve acid blockers long term (its dangerous)
- There are numerous factors which can cause GERD, and hiatal hernias are one of them
- Hiatal Hernias can contribute to GERD directly and should be investigated for and treated appropriately
What Is Hiatal Hernia
Hiatal hernia is a condition in which parts of the abdominal contents including the Gastroesophageal Junction and the stomach, a displaced above the diaphragm. This hernia is different that the abdominal hernia you may think about when abdominal contents protrude through a muscle wall.
There are various types of Hiatal Hernia, each differentiating the extend of the protrusion and how severe it is.
The diagram below identifies normal as well as three types of Hiatal Hernias [1]. (Diagram from Lebenthal et al).
Why is Hiatal Hernia Significant?
The significance of hiatal hernia has been debated for decades [1]. Initially the importance was overemphasised, and now it seems like hiatal hernias are nearly neglected [1]. In my clinical practice, I encounter countless patients with hiatal hernia, who were told two misleading things:
- Hiatal hernias are clinically insignificant (ie doesn't need to be treated or managed)
- There's nothing we can do for hiatal hernias
This isn't always the case!!
Type 1 hiatal hernias (sliding) are closely associated with Gastroesophageal reflux disease. GERD may lead to reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma [1]. In fact, patients with hiatal hernia are significantly more likely to present with GERD. The most common
How Hiatal Hernia is Liked to Gastro-esophageal Reflux Disease
Gastro-esophageal reflux disease (GERD) occurs when the defensive factors can't keep up with the aggravating factors.
The defensive factors include [1]:
- Gastroesophageal junction (GEJ in the image above)
- Esophageal acid clearance
- Tissue resistance
The aggravating factors include [1]:
- Gastric acid secretion
- Delayed gastric emptying
GERD is More Than Just Acid Reflux
GERD may be known as acid reflux, but it's NOT usually a result of too much acid (related article here). Hiatal hernia must always be considered and treated if appropriate.
Up to about 90% of patients with reflux esophagitis have Hiatal Hernias [1]. In fact, the size of the hernia is also important.
GERD Shouldn't Be Treated Exclusively with Acid Blocking Medications
We know acid blockers are not safe beyond a year (article here). In fact, even the manufactures of these meds state they aren't meant for long term use (article here).
Stomach acid is crucial for overall health and digestive function. Being on an acid blocker long term can lead significant side effects. The diagram below showcases the importance of stomach acid.
Explore All Causative Factors of GERD
GERD is caused by a few different factors - and Hiatal hernias are just one.
We need to start investigating the causes of GERD rather than simply taking acid blocking medications to mask the symptom.
Review
GERD is a commonly encountered symptom in clinical practice. Many patients experience it and tack it up to excess stomach acid production. In reality, that is rarely the cause, and acid blocking medications not only don't address the underlying issue, but oftentimes lead to a myriad of health complications.
Hiatal Hernias are a common culprit behind GERD or acid reflux, and treatment can sometimes be alleviated by other means.