According to the Journal of the American Medical Association (JAMA), more than one-third of adults in the U.S. experience heartburn at least once a month.
Heartburn is a burning sensation in the chest that occurs when stomach acids travel back up the esophagus. Some patients may also experience a bitter or sour taste in the throat and mouth. Symptoms of heartburn may get worse after eating or when lying down.
Other symptoms include persistent cough, excessive clearing of the throat and sore throat. There can be intolerance of certain foods, nausea, regurgitation, repeated swallowing and sometimes vomiting. Frequent heartburn can make it difficult to eat or swallow and may be a sign of a more serious condition, like a hernia.
What is a hiatal hernia and how can it cause heartburn?
A hiatal hernia is a condition in which a portion of the stomach protrudes through an opening in the diaphragm (hiatus) into the chest cavity. There are two main types of hiatal hernias:
A sliding hiatal hernia is the most common type of hiatal hernia and occurs when the stomach and the section of the esophagus that joins the stomach, the gastroesophageal junction, move upward into the chest through the hiatus.
A paraesophageal hernia (PEH) is a less common type of hiatal hernia, in which a portion of the stomach or other organs push through the hiatus, next to the esophagus, into the chest, which can cause additional problems.
Both types of hiatal hernias can cause similar symptoms such as heartburn, chest pain and difficulty swallowing.
Hiatal hernias are most common in people over 50 and can be caused by a number of factors, including obesity, pregnancy and chronic coughing. Treatment options include lifestyle changes, medications and in some cases, surgery.
What are the symptoms of a paraesophageal hernia?
The symptoms of a paraesophageal hernia (PEH) can vary depending on the size of the hernia and the extent to which it is compressing the surrounding organs. Some common symptoms of a PEH include:
- Heartburn – A burning sensation in the chest that can be felt behind the breastbone and can sometimes be mistaken for angina or a heart attack.
- Chest pain – A sharp or dull pain in the chest, which can be made worse by lying down or bending over.
- Difficulty swallowing – A feeling that food is getting stuck in the throat or chest.
- Acid reflux – A sour taste in the mouth caused by stomach acid flowing back into the esophagus.
- Belching – The feeling of gas coming up through the chest and throat.
- Nausea – A feeling of sickness or an upset stomach.
- Water brash – A condition characterized by an excessive flow of saliva that is accompanied by a sour or bitter taste in the mouth. Water brash is caused by an increase in acid in the stomach that flows back into the esophagus (acid reflux) and irritates the lining of the esophagus. The increased acid causes the salivary glands to produce more saliva in an attempt to neutralize the acid and wash it away. This excess saliva can then cause a sour or bitter taste in the mouth.
- Aspiration – Aspiration is the medical term used to describe the accidental inhalation of foreign materials, such as food, liquid, vomit or saliva, into the lungs. This can occur when the normal swallowing mechanism is disrupted, or when a person is unable to properly control the muscles used for swallowing and breathing. Aspiration can cause a range of health problems, depending on the type and amount of material inhaled, and the person's overall health. Some common symptoms of aspiration include coughing, choking, wheezing, chest pain and difficulty breathing. In some cases, it can also lead to pneumonia or other lung infections, which can be serious and even life-threatening.
- Vocal changes – The hernia can put pressure on the recurrent laryngeal nerve, which is responsible for controlling the muscles of the larynx (voice box), and the esophagus. This pressure can cause hoarseness, weakness of the voice or even complete loss of voice. It can also cause difficulty swallowing, pain or discomfort while swallowing or speaking and a lump-like sensation in the throat.
It is important to note that some people with a paraesophageal hernia may not experience any symptoms at all. In some cases, the hernia is found incidentally during a medical examination for another condition.
If you have any of these symptoms, it is important to see a doctor for a proper diagnosis. Some of these symptoms can also be caused by other conditions such as acid reflux disease or gastritis, so a proper evaluation is important.
How is a hiatal hernia detected?
The workup for a hiatal hernia typically includes tests such as an upper gastrointestinal (GI) series or an upper endoscopy (EGD). The tests can help to confirm the diagnosis and determine the size of the hernia. In some cases, other tests such as a pH test, EndoFLIP, or high-resolution manometry may also be ordered to evaluate for any acid reflux or other issues related to the hernia such as difficulty swallowing.
Depending on the symptoms and the results of the tests, the provider may then recommend treatment options such as lifestyle changes, medication, or surgery.
What are Proton pump inhibitors?
Proton pump inhibitors (PPIs) are a class of medications that are commonly used to treat acid-related conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers. They work by reducing the amount of acid produced by the stomach.
While PPIs are generally considered safe when used as directed, long-term use of these medications can have some potential complications, such as:
- Increased risk of infection
- Bone fractures
- Kidney disease
- Nutrient deficiencies
- Interactions with other medications
It is important to note that the risks of long-term PPI use may vary depending on the individual and the underlying condition being treated. If you are taking PPIs and have any concerns, it is best to speak with your healthcare provider about your options.
When do I need surgery for GERD?
If you have Gastroesophageal Reflux Disease (GERD), your healthcare provider may recommend surgery if:
- Even after taking medications like proton pump inhibitors (PPIs), you have recurring symptoms of GERD:
- Acid reflux
- Difficulty swallowing
- If you have complications of GERD:
- Barrett’s esophagus
- Recurrent esophageal bleeding
- If you have a hiatal hernia, which can cause reflux
- If the medications to combat GERD don’t work or you develop side effects from the medications.
- If you prefer surgery over long-term medical therapy for GERD.
- If you are obese, surgery could be a weight-loss option, as well as a way to improve GERD symptoms.
It is important to note that surgery for GERD is considered a last resort and is typically only recommended for patients who have not responded to other forms of treatment. Your surgeon will conduct a thorough evaluation and will explain to you the risks and benefits of surgery.
When do I need surgery for a PEH?
If you have a paraesophageal (PEH) hernia, your healthcare provider may recommend surgery if your symptoms include:
- Difficulty swallowing
- Chest pain
- Anemia (low red blood cells)
- Repeating episodes of heartburn, regurgitation or chest pain
- If the hernia is strangulating (pinching) the stomach, this could lead to:
- Necrosis (tissue death) of the stomach
- An obstruction of the stomach
- Perforation of the stomach
- If the hernia, especially a PEH, is causing reflux symptoms
- If the patient has a recurring hernia that was previously repaired.
- If the hernia is large and causing complications.
It is important to note that surgery for PEH is considered a last resort and is typically only recommended for patients who have not responded to other forms of treatment. Your surgeon will conduct a thorough evaluation and will explain to you the risks and benefits of surgery.
For more information about heartburn, hernias and the healthcare providers at Lovelace Medical Center who can help you with these ailments, visit our web page for the Lovelace Heartburn Clinic.