Hiatus Hernia

The term hiatus hernia refers to a protrusion of the stomach above the diaphragm. Technically speaking the usage of the term “hernia” is incorrect, as a hernia specifically refers to the protrusion of an organ through an abnormal opening. In the case of a hiatal hernia it is the protrusion of the fundus of the stomach through the normal opening of the esophageal hiatus, a hole that pierces the diaphragm and allows the esophagus to meet up with the stomach. The conventional medical perspective states that the etiology of hiatus hernia is often idiopathic, but in a minority of cases is related to a congenital abnormality or is secondary to trauma, such as a tear in the diaphragm. An alternate explanation, and one that would suit the vast majority of cases, is that a hiatus hernia is caused by the elongation or rupture of the phrenoesophageal ligament (PEL), which extends from the diaphragm and adheres the external esophageal sphincter to the internal esophageal sphincter located in the wall of the esophagus.

This displacement of the PEL allows a portion of the stomach to rise above the diaphragm. The cause of this is not entirely known but it is thought that the PEL becomes displaced because of an increase in the intra-abdominal pressure, which forces the stomach upwards. Thus anything that increases intra-abdominal pressure, such as bending or lifting, especially after eating, would put an upward pressure upon the stomach, forcing a portion of it through the esophageal hiatus. In a sliding hiatus hernia the gastroesophageal junction and a portion of the stomach are pushed up above the diaphragm. In paraesophageal hiatus hernia the gastroesophageal junction is in the normal location but a portion of the stomach is adjacent to the esophagus rises above the diaphragm. (Berkow 1992, 750; Rubin and Farber 1990, 354-55)

Approximately 40% of the population suffers from hiatus hernia, although in many cases these patients are asymptomatic or only occasionally affected (i.e. by overeating, or eating certain foods such as flour products, spicy foods, etc.). A paraesophageal hiatus hernia is generally asymptomatic but unlike a sliding hiatus hernia, it may become occluded and strangulate. Small amounts of blood or even a massive hemorrhage may occur with either type of hiatus hernia. (Berkow 1992, 750; Rubin and Farber 1990, 354-55)

Medical Treatment

The medical treatment of hiatus hernia is in large part similar to the treatment of GERD, relying upon the usage of antacids, acid-secretion inhibitors, and surgery. In the latter case surgical options have a very limited rate of success.

Holistic Treatment

From a herbalist’s perspective the etiology of hiatus hernia is similar to that of GERD, and thus all approaches indicated under GERD are applied here as well. As mentioned, the term “hernia” confuses the diagnosis and therefore the treatment options. Fundamentally there are two basic components to the condition: a structural weakness and misalignment of the muscles in the mediastinum, and either an acute or chronic increase in the intra-abdominal pressure. The primary cause of structural problems, apart from inherent constitutional weaknesses, is typically caused by poor gastric motility, often associated with overeating, which stretches and weakens the muscles that hold the esophagus firmly in the esophageal hiatus. The cause of a chronic increase in intra-abdominal pressure is similar: poor motility and the excessive fullness of the stomach. In the latter case this can be caused by eating to excess, or from poor food combinations that impairs gastric motility and promotes fermentation and gas, which distends the stomach causing it to rise above the esophageal hiatus. Other causes of a chronic increase in intra-abdominal pressure are chronic adrenal stress, which causes the diaphragm to be chronically contracted, and abdominal obesity. Thus measures are taken to ensure proper gastric motility through herbs and diet, reducing sympathetic stress, and implementing a weight loss regimen. If the hiatus hernia was caused by injury, such as the tearing of the diaphragm, the underlying mechanism is usually an inherent weakness in these tissues, once again, caused by similar factors as in GERD.

Although dietary modifications, herbal and supplemental therapies can be seen to be highly effective in treating hiatus hernia, there are some additional physical techniques that can be employed to push the stomach back down below the esophageal hiatus. Once technique is to have the patient drink 500-1000 mL of water upon awakening, while sitting in bed, and then immediately standing erect on his or her toes, and then allowing all the weight of the body to come down upon the heels. This is repeated ten times, and every morning over several weeks. The idea here is to use the weight of the water to pull the protrusion down and slip the stomach back under the diaphragm.

Another technique is massage, working on the surface of the surrounding tissues with the fingers, and gradually working deeper, softening any muscular tension, ensuring that the patient is able to release any muscle tension in thorax. Care must be taken not to place pressure upon the xyphoid process or the floating ribs during massage. Once the patient has relaxed sufficiently the practitioner can stand behind the patient a place a tennis ball under the ribs, and role it back and forth along the edge along the diaphragm, pushing into and down against the stomach, once again being careful not to push directly on the xyphoid process. This technique often brings about immediately relief, but must be accompanied by the dietary modifications outlined under GERD.