Disclaimer: This podcast is for informational purposes only and is not intended to be used as personalized medical advice.

Caitlin Whyte (Host): Chest pain, bloating and burping can all be signs of a hiatal hernia. But what exactly is that? Joining us today to discuss hiatal hernias and gastroesophageal reflux disease is Dr. Allison Porter, a General Surgeon with specialty training in minimally invasive surgery and robotic surgery at Skagit Regional Health. Welcome to Be Well, the podcast from Skagit Regional Health. I'm your host, Caitlin Whyte. Doctor, to kickoff, our conversation here, what is a hiatal hernia?

Allison Porter, MD, FACS: Sure. So the definition of a hiatal hernia is when a portion of the stomach rises above the diaphragm. And the diaphragm is a very large muscle that extends all the way across the body. And every time you breathe, it moves down to help your lungs expand. And then it moves back up again to help you exhale. And it has a natural hole called the hiatus, and that is so the esophagus can pass through the diaphragm to carry food from your mouth down to your stomach. And the stomach's natural position is below the diaphragm. But for many people, a little bit, or sometimes a lot of the stomach will start rising up above the diaphragm, basically due to various pressures or tissue breakdown. And when that happens, it's called a hiatal hernia.

Caitlin Whyte (Host): And then how is this different from gastroesophageal reflux and what is that condition?

Dr. Porter: So they're related and gastroesophageal reflux is when food, liquid or acid from the stomach washes back up into the esophagus. And it's actually normal for everybody to have a little bit of that gastroesophageal reflux. But for some people, it happens more than it's supposed to. And that's when they'll get symptoms that require treatment. And the way they're related to a hiatal hernia is, when the stomach is in its appropriate position below the diaphragm, then the muscles of the stomach, esophagus and diaphragm are all lined up.

So the junction, which is called the gastroesophageal junction, it works as a one-way valve or it's supposed to. So food and liquid can go down, but then food, liquida and acid don't go backward from the stomach back up into the esophagus. So when someone gets a hiatal hernia, then those muscles aren't lined up appropriately anymore. And the one-way valve starts being more like a two-way valve where that food, liquid and acid can kind of go both directions. And the esophagus isn't really made to tolerate a large amount of acid going backward. And when food goes backward, then sometimes it goes all the way up the esophagus and ends up in someone's mouth or throat. And so the gastroesophageal reflux is just the situation in which these things are going backward when they're not supposed to be.

Caitlin Whyte (Host): So then what are some medical and surgical treatments for gastroesophageal reflux disease?

Dr. Porter: There are quite a few different treatments and they all vary in how well they work and who they work for. They start with basics like natural remedies and over-the-counter medications, and there are also lifestyle modifications. And then at the kind of more drastic end is surgery. And I do a lot of anti-reflux surgery in my practice, but I don't do it for every single person who has gastroesophageal reflux disease. The natural remedies that help some, some of those include things like apple cider vinegar and licorice.

They sort of can help some people, but they don't always provide complete relief. And sometimes they don't work for people, but I always recommend giving them a try because they can help and often don't hurt. The lifestyle modifications would be things like avoiding large meals, right before bedtime and avoiding spicy foods. There are other foods that can make reflux worse. Like chocolate, caffeine and heavy meals can make it worse. Some of my patients have to sleep with the head of the bed elevated or in a reclined position rather than flat because their reflux will cause them to have symptoms of choking at night. So those are some of the lifestyle modifications.

And then the over-the-counter medications kind of the starter ones are things like Tums or Rolaids. And then there are stronger medications. One kind is called an H2 blocker and Famotidine is the most used one right now. And then beyond that, there is a class of medications called proton pump inhibitors, and the most common one is Omeprazole.

Historically the H2 blockers and proton pump inhibitors were prescription medications, but because they have a fairly low side effect profile, they can be purchased over-the-counter. So some people get the prescription from their physician and others will just buy them over-the-counter, like at a bulk warehouse, for example.

Caitlin Whyte (Host): Okay. And then if I have a hiatal hernia, does that need to be fixed with surgery?

Dr. Porter: Not necessarily, there are many people that have a hiatal hernia, but don't need to have it fixed. I try to compare it to like a mole on your skin. Lots of people have lots of moles, but it doesn't mean that every single one needs to be removed. There are certain ones that require treatment or excision. And the same is true for hiatal hernia. I would say most hiatal hernias don't actually need surgery, but there are people that need to have them repaired or benefit from repair. I kind of divide hiatal hernias into two different classifications.

One is a small hiatal hernia that causes reflux and the other is the large hiatal hernia where there's a significant anatomic abnormality. The whole stomach can be in the wrong position or the stomach can be twisted on itself. So the people who have a small hiatal hernia, the ones that are candidates for antireflux surgery would be the ones who have failed the non-operative management, which is all of the kind of things I mentioned before, the natural remedies, the over-the-counter, the medications and prescription medications, et cetera.

There's also a group of patients who are not looking in, they prefer not to take these medications for their entire lives because there can be side effects if you take, you know, high-dose proton pump inhibitors for decades and decades. So those patients, you know, some of those patients have their symptoms are fairly well controlled on medications, but the prospect of taking those medications for life can mean that you're taking on a certain risk of the side effects from the long-term use. So that's kind of the small hiatal hernia classification. So it's people who are on high-dose medications or want to get off their medications.

And then the people who have a large hiatal hernia, like I said, some of those people will have half or more of their stomach in the wrong position. And sometimes there's a twist to the stomach and that can be a problem kind of in real time. Meaning sometimes they can't eat right. Like food just won't go down. Because the stomach's, it's almost like a water balloon. It can be partially twisted on itself and it can turn into an emergency if it twists a little bit further to the point where the stomach won't empty. So those patients are generally candidates for surgery, depending on how bad their symptoms are.

And we take into factor, you know, a lot of other things like what their other medical problems are and how well they would tolerate surgery and how long surgery would take, et cetera.

Caitlin Whyte (Host): Great. Talking about these two conditions, as we wrap up, is there anything else that you'd like to share?

Dr. Porter: One thing I will say is that having a hiatal hernia, as a surgeon, I see the almost like a normal thing. I do see people who seem very stressed out if they had an X-ray or a CT scan or an endoscopy that said they had a hiatal hernia and they wonder if something's wrong with them. And I would like to reassure people who are told they have a hiatal hernia that they come in a very wide variety.

There are kind of classifications of them. So it's not something to get worried or stressed out about, but it's important to get the appropriate follow-up if you do have one diagnosed to determine if it's something that needs to be treated at all or treated only with medications or would require referral to a surgeon.

Caitlin Whyte (Host): Well, doctor thank you for your time and for this great information. We so appreciate you and your work. For more information, go to SkagitRegionalHealth.org. And thanks for listening to Be Well, the podcast from Skagit Regional Health. If you found this conversation helpful, please be sure to tell a friend and subscribe, rate and review this podcast on your favorite app. I'm Caitlin Whyte. Stay well.

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