Are your symptoms due to a hiatal hernia?
What is a hiatal hernia?
It is helpful to visualize the anatomy to fully understand what a hiatal hernia is. First picture the diaphragm. It is the horizontal muscular structure that divides the chest cavity from the abdomen. It lies underneath the ribcage. The diaphragm has a hole in the center called the hiatus, where the esophagus passes through and connects to the stomach. At the bottom of the esophagus, below the diaphragm, sits the lower esophageal sphincter (LES). Also passing through the hole is the vagus nerve.
A hiatal hernia is when the stomach pushes up into and/or through the hiatus. This disrupts proper functioning of the LES and puts pressure on the vagus nerve. When the LES isn’t functioning, acid reflux and food regurgitation occurs. When there is pressure on the vagus nerve, the autonomic nervous system is affected, causing digestive upset, heart palpitations, shortness of breath, and symptoms of anxiety.
There is a range of severity of a hiatal hernia from upward pressure (considered hiatal hernia syndrome) to the stomach bulging to a greater degree through the hiatus. The latter is visible with an endoscopy. Surgical repair of a hiatal hernia is considered major surgery and is only done in extreme cases.
Possible symptoms of a hiatal hernia
Acid reflux and food regurgitation
Chronic cough and throat clearing
Shortness of breath, shallow breathing, and asthma
Trouble swallowing and globus sensation (feeling of something stuck in the throat)
Feeling of fullness or pain in chest and/or mid-section
Digestive upset
Heart palpitations
Anxiety
Blood pressure spikes
Fatigue and mental dullness
What causes a hiatal hernia?
Congenital—a wide diaphragmatic hiatus or a weakened diaphragm
Aging—as we age the incidence of hiatal hernia increases
Trauma—abdominal surgery, abdominal exercises (crunches), vomiting, horseback riding, jumping, etc.
High abdominal pressure—pregnancy, obesity, chronic constipation, COPD
Poor posture—slouching forward
Hyper-mobility—Hyper-mobility can disrupt connective tissue and weaken muscles
Dietary choices (see below)
How to discover a hiatal hernia or hiatal hernia syndrome
As mentioned above, a hiatal hernia can be diagnosed during an endoscopy. The way I assess if a hiatal hernia is part of the symptom presentation is by muscle testing. Pushing upward on the stomach causes weakness of the testing arm, and pulling down on the stomach restores strength. Unless symptoms are extreme, an endoscopy can be avoided. In fact, many people find out that they have a hiatal hernia when getting an endoscopy for unrelated symptoms.
How I treat a hiatal hernia
When clients come in with some of the symptoms listed above, I like to test for a hiatal hernia. If I detect that the stomach is pushing up into the diaphragm, I do a bodywork maneuver to loosen up the tissue and pull the stomach back into place. This can be a bit uncomfortable, but the discomfort is brief. Typically, I hear stomach gurgling, the tissues soften and the client feels almost immediate relief.
How to manage a hiatal hernia at home after a manipulation
Work on upright posture
Avoid foods that irritate the stomach: Coffee/caffeine, chocolate, carbonated beverages, alcohol, spicy foods, fatty foods, tomatoes, citrus, onions/garlic, peppermint
Supplements to manage hypo/hyper-acidity and stomach inflammation
Dietary modification: avoid overeating and large meals, chew food thoroughly, only eat in a calm environment, avoid eating 2-3 hours before bedtime
Heel drops - On waking, drink 16 oz of warm water. Stand on tip toes, and drop onto heels 10-12 times. This pulls the stomach downward.
Elevate the head of your bed a few inches
If your symptoms match the list above, or you have more specific questions, please let me know at your next appointment. Understanding and addressing a hiatal hernia can truly improve your quality of life.
Marie's Body of Knowledge
How can physical therapy help with a hiatal hernia?
In general when a patient in physical therapy reports symptoms of acid reflux, upper abdominal pressure, shallow breathing, abdominal bloating, and poor digestion/constipation, it may be an indication that they have a hiatal hernia. Short of an endoscopy to confirm a hiatal hernia, physical therapists trained in visceral manipulation through the Barral Institute are able to evaluate the abdominal sphincters, vagus nerve, and mobility of the internal organs through manual therapy and listening techniques.
Barral identifies 5 digestive sphincters:
Lower esophageal sphincter (LES or cardiac) that connects the lower esophagus to the stomach.
Pyloric sphincter that connects the stomach to the small intestine.
Sphincter of Oddi that connects the bile/pancreatic ducts to the stomach.
Duodenal-jejunal junction that is the functional transition point between the duodenum and the upper small intestine.
Ileocecal sphincter that connects the small intestine to the large intestine.
If one or more of these sphincter transition points is in spasm due to stress, decreased organ myofascial mobility, surgery, or trauma the other sphincters around it may become tense with myofascial restrictions and disrupt and slow down the normal digestion process.
In the case of a hiatal hernia, the stomach fascia may become restricted pulling the stomach upward. This may result in the stomach getting stuck on the underside of the diaphragm putting pressure on the LES. The stomach may also develop myofascial restrictions that inhibit the stomach's ability to expand fully, causing pressure on the LES. In addition, when the pyloric sphincter spasms it delays food from moving out into the small intestine. This delay causes food to ferment in the stomach resulting in gas and pressure back flowing into the LES.
A visceral mobilization-trained physical therapist is able to manually identify myofascial restrictions in the digestive sphincters, vagus nerve, internal organs, and diaphragm. The goal of physical therapy is to use myofascial mobilization techniques on the identified restrictions and improve overall digestive function. The physical therapist will also teach home self-mobilization techniques to maintain balance. If you have hiatal hernia symptoms or other digestive issues, I encourage you to seek the help of a physical therapist trained in visceral mobilization to improve your gut health.