Article Archive
July/August 2020

Hiatal Hernia: Impact on the Aerodigestive Tract and Swallowing
By Jennifer M. Pusins, CScD, CCC-SLP, BCS-S, IBCLC; Taniya Jiwani; Ashley V. Persaud; and Aislynn Baretto
Today’s Geriatric Medicine
Vol. 13 No. 4 P. 18

Knowledge of the repercussions of swallowing dysfunction related to hiatal hernia is key to management.

Hiatal hernias are characterized by displacement of some portion of the stomach into the thorax. They occur relatively frequently, affecting 10% to 50% of the general population, and are associated with morbidity and mortality. Hiatal hernias have the potential to cause a wide range of nonspecific symptoms and multisystem clinical signs, including aerodigestive tract systems.1,2 Diagnosis and treatment can be challenging depending on the clinical presentation.

Swallowing problems are a common complaint of patients with various types of thoracic disease. Speech-language pathologists (SLPs) are frequently consulted to assess and manage swallowing disorders, which may stem from a wide range of etiologies. According to Logemann, swallowing refers to the act of deglutition beginning with placement of food in the mouth through the oral, pharyngeal, and esophageal stages of the swallow until the material passes into the stomach through the gastroesophageal junction. Dysphagia results from difficulty moving food from the mouth to the stomach.3

Dysphagia can cause serious consequences including malnutrition, dehydration, aspiration pneumonia, and death. With or without gastroesophageal reflux, dysphagia is a commonly reported symptom of a hiatal hernia. It’s imperative for SLPs to be able to identify the signs and symptoms of swallow dysfunction associated with hiatal hernias in order to provide appropriate assessment and management.

Types of Hiatal Hernias
The presence of a hiatal hernia indicates that elements of the abdominal cavity, most frequently the stomach, are displaced though the esophageal hiatus of the diaphragm into the mediastinum.4 Anatomic classification of hiatal hernia identifies four types.

Type I (Sliding Hernia)
Characterized by a widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal membrane allowing a portion of the gastric cardia to herniate upward,2 type I hernias represent more than 90% of cases and are known to be associated frequently with gastroesophageal reflux disease, including more severe degrees of esophagitis and Barrett’s esophagus.5-7 Gastroesophageal reflux disease results from distortion of the normal anatomic characteristics of the gastroesophageal junction and lower esophageal sphincter.8 While this type of hernia is the most common, it’s also the most difficult to diagnose.

Type II (Pure Paraesophageal Hernia)
Type II hiatal hernias are characterized by a localized defect in the phrenoesophageal membrane, while the gastroesophageal junction remains fixed to the preaortic fascia and the median arcuate ligament with the gastric fundus serving as the leading point of herniation. They do not result in esophagitis or gastroesophageal reflux disease; however, ingestion of food/liquid enters the herniated stomach, which leads to distention. Symptoms may include fullness after meals, palpitations, shortness of breath, pain, dysphagia, regurgitation, and peptic ulcers.2

Type III
Type III—a combination of types I and II—is characterized by a progressive enlargement of the hernia through the hiatus, stretching the phrenoesophageal membrane, and displacing the gastroesophageal junction above the diaphragm, which adds a sliding component to the type II hernia.2 This type of hernia accounts for approximately 90% of all paraesophageal hernias and may enlarge to draw even more of the stomach into the chest.8

Type IV
Type IV hiatal hernias are characterized by a large phrenoesophageal membrane defect that allows gastric and nongastric viscera (eg, spleen, peritoneum, and small bowel) to enter the thoracic cavity.8 Symptoms may include postprandial fullness or pain, dysphagia, iron-deficiency anemia secondary to chronic blood loss from incarcerated gastric pouch, and aspiration of regurgitated material.2

Impact of a Hiatal Hernia on the Aerodigestive Tract
A hiatal hernia may cause difficult or labored breathing, known as dyspnea, due to the extent of the protrusion of the hernia and organs into the thoracic cavity. Relaxation at the level of the diaphragmatic crura results from the aging process and is thought to be the cause of more frequent, larger hiatal hernias in the geriatric population. Large hiatal hernias can lead to chest pain, dyspnea, and rare complications such as pulmonary edema and cardiac failure depending on the extent to which the hernia compresses the heart and pulmonary veins. Dyspnea occurring after large meals is likely due to pulmonary congestion from compression of the left atrium and right pulmonary vein.9

A hiatal hernia may also occupy space within the thorax leading to restrictive lung disease symptoms, including reduced total and vital lung capacity as well as gas trapping. Reduced lung ventilation and perfusion has been reported to occur in the basal segments adjacent to the hernia. Reduced total lung capacity and vital capacity are associated with increasing hernia size. Reduced total lung capacity due to a hiatal hernia may be explained by a mild extraparenchymal restrictive defect similar to a large pleural effusion or pneumothorax.10

Restrictive lung disease may also occur due to a hiatal hernia secondary to pulmonary fibrosis associated with gastroesophageal reflux. The presence of a hiatal hernia is also associated with increased residual volume/total lung capacity ratio, suggestive of gas trapping, which appears to be related to the size of the hernia. Increased residual volume is a measure of gas trapping and is commonly observed in conditions associated either with loss of thoracic elastic recoil, dynamic airway obstruction, or both. The removal of a large hiatal hernia may improve elastic recoil and airway conductance, as surgical repair is associated with improved lung volumes and reduced gas trapping.10 Respiratory symptoms may include shortness of breath, cough, and chest pain. The dyspnea associated with hiatal hernias can be unrelated to preexisting pulmonary disease.9 Many medical providers do not associate chronic respiratory symptoms with the presence of a hiatal hernia, so appropriate clinical management can be delayed or missed.

Additionally, a hiatal hernia may cause pressure elevation in the area of the gastroesophageal junction due to impingement of the diaphragmatic hiatus in the distal herniated stomach and proximally as a result of basal pressure of the lower esophageal sphincter.11 When a food bolus moves down the esophagus and into the herniated portion of the stomach, the propulsion of the bolus stops due to lack of effective contraction of the gastric fundus and impingement of the body of the stomach by the diaphragmatic hiatus. The presence of a hiatal hernia may also cause a loss of distal fixation of the esophagus, making propulsion less effective.12,13 This mechanical obstruction precipitated by the impingement around the herniated stomach leads to accumulation of food in the herniated portion of the stomach, resulting in dysphagia, early satiety, and epigastric pain.12 When proximal gastric distention or subsequent swallows result in lower esophageal sphincter relaxation, there’s a retrograde flow of ingested food and the sensation of regurgitation.13

Impaired bolus transit is a common pathophysiologic finding associated with hiatal hernias. Emptying of the distal esophagus is a function of the elastic recoil of phrenoesophageal attachments restoring the esophagus to its normal resting length after peristalsis-associated shortening.14 Both peristalsis-associated shortening and the subsequent recoil are reduced in the presence of a hiatal hernia, suggesting that hiatal hernias compromise this function.15 Hiatal hernias can also alter the pressure dynamics within the gastroesophageal junction, leading to a functional obstruction in some cases. When there’s increased gastroesophageal junction relaxation pressure in the context of a small type I hiatal hernia, careful analysis of the gastroesophageal junction must be done prior to making a diagnosis of esophageal dysmotility.14

The prevalence of gastroesophageal reflux in the presence of a hiatal hernia is approximately 68% of cases. The pathophysiologic relationship between hiatal hernias and gastroesophageal reflux is suggested to be due to the migration of the lower esophageal sphincter and the gastroesophageal junction into the mediastinum. The negative pressure in the thoracic cavity results in an incompetent gastric cardia, which allows the gastric contents to be refluxed into the distal esophagus. The higher frequency of transient lower esophageal sphincter relaxation in the presence of a hiatal hernia and the high concentration of acidic material above the level of the diaphragm may also contribute to the clinical manifestations due to the esophageal mucosa being subjected to prolonged exposure to gastric acid.16 Additionally, postprandial gastroesophageal reflux symptoms are more often reported in the presence of a hiatal hernia.

The size of a hiatal hernia is also associated with changes in clinical presentation, including the function of the lower esophageal sphincter and esophageal body, amount of esophageal acid exposure, and degree of esophageal mucosal injury. Larger hiatal hernias typically present with reduced esophageal peristalsis and more prevalent respiratory symptoms. Although gastroesophageal reflux is an infrequent complication of type II hiatal hernias, it may present in the form of respiratory complications, which can be very severe. A type II hiatal hernia should be suspected in all cases of long-lasting unexplained dyspnea, new onset episodes of bronchospasm, and with rapid worsening of previously diagnosed nonallergic asthma.15

Clinical Implications: Swallowing
The upper aerodigestive tract serves two important functions—respiration and swallowing. A stable, coordinated relationship between respiration and swallowing in healthy adults has been long supported by research literature. Structures active during breathing and swallowing serve purposes of airway opening, airway protection, and bolus propulsion. Precise coordination of the respiratory-swallow pattern must occur to reduce the risk of pulmonary aspiration.

Swallowing typically occurs during the expiratory phase of respiration between middle and lower lung volumes, which promotes hyolaryngeal elevation and excursion, airway closure, and opening of the upper esophageal sphincter.11,17,18 During the moment of swallowing there’s a respiratory “pause” known as apnea, which occurs to accommodate the act of swallowing. The onset of this respiratory pause is associated with protective adduction of the true vocal folds followed by a brief exhalation indicating respiration has resumed.11,19

Variations in this coordinated respiratory-swallow pattern may increase the risk for pulmonary aspiration. The most predominant breathing and swallowing pattern is characterized by exhale-swallow-exhale, with the second most common pattern being inhale-swallow-exhale.20-23 Inspiration after the swallow may result in preswallowed or residue material entering the unprotected airway after the swallow.

During swallowing, respiratory system recoil generates subglottic air pressure.12 The amount of pressure generated is dependent on the volume of air in the lungs during the time of swallow onset. Variations in lung volumes have been associated with significant durational differences in the biomechanics of pharyngeal swallowing.24 When the act of swallowing occurs with lung volumes above functional residual capacity, higher-than-atmospheric pressure levels have been consistently detected in the subglottic space during the pharyngeal phase, with a significant linear relationship between lung volume and deglutitive subglottic air pressure.24,25 Research has found that 95% of swallows occur at a lung volume of 43% to 64% of vital capacity, which has been suggested to be the lung volume range that promotes the safest, most efficient swallow physiology.21 When respiratory drive is modified by excessive carbon dioxide in the bloodstream or changes in the respiratory mechanical or flow-restrictive load, increases in swallow frequency and laryngeal irritation have been found.26

Dysphagia is highly prevalent among individuals with chronic respiratory diseases.27 Dysphagia also causes respiratory complications, such as respiratory infections and pneumonia, further demonstrating the strong relationship between these factors and aspiration pneumonia. Given the respiratory symptoms associated with a hiatal hernia, especially when symptoms follow a large meal, it’s very likely an SLP will be consulted due to concerns for dysphagia. It is essential for the SLP to be knowledgeable on the various etiologies of dysphagia, including the impact of hiatal hernias, to ensure adequate care is provided and appropriate referrals are provided. Understanding the relationship between hiatal hernias, gastroesophageal reflux, and respiratory manifestations will promote appropriate assessment and treatment of dysphagia to prevent the potential severe complications of swallowing dysfunction. Factors affecting respiratory control and respiratory system mechanics may need to be assessed when treating individuals with dysphagia. Additionally, any factors that affect lung volume and recoil, such as body position during meals, may need to be considered when managing swallowing difficulties.

It’s also common for individuals with a hiatal hernia to complain of dysphagia. A hiatal hernia may cause dysphagia by deteriorating esophageal peristalsis, and the loss of stretching of the esophagus due to damage of phrenoesophageal attachments may also further reduce esophageal peristalsis. Additionally, the presence of a hiatal hernia itself may cause dysphagia, as individuals with normal esophageal peristalsis still present with swallowing difficulties.28

Gastroesophageal reflux is commonly associated with dysphagia and respiratory symptoms. Esophageal strictures, esophageal dysmotility, and hiatal hernias are also potential factors in the development of dysphagia. Pulmonary aspiration and stimulation of the vagus nerve by reflux material are reported to be two main mechanisms in the development of respiratory symptoms related to gastroesophageal reflux. Impaired esophageal peristalsis also likely plays a role in the development of both dysphagia and respiratory symptoms. Acute esophagitis resulting in submucosal edema, loss of muscle fibers, and increase in submucosal collagen due to chronic inflammation are additional possible factors affecting the development of esophageal dysmotility.28

The aerodigestive complications associated with a hiatal hernia may significantly influence the safety and volume of oral intake. SLPs must thoroughly understand the scope of esophageal disorders and their effect on oropharyngeal swallow function in order to provide appropriate intervention. Knowledge of abnormalities in esophageal structure and function is essential to identify clinical symptoms of esophageal dysphagia as well as the presence of esophageal dysfunction on instrumental examinations. Understanding the dynamic relationship between oropharyngeal and esophageal swallow function will allow the clinician to provide high-quality intervention and reduces the likelihood that the underlying cause of dysphagia will go undetected.

—  Jennifer M. Pusins, CScD, CCC-SLP, BCS-S, IBCLC, is an assistant professor and clinical supervisor at Florida’s Nova Southeastern University. Pusins is a board-certified specialist in swallowing and swallowing disorders and her area of clinical expertise is in the assessment and management of dysphagia across the life span. She’s presented at the state, national, and international levels on various topics related to dysphagia.

— Taniya Jiwani is a graduate student clinician pursuing a Master of Science in Speech-Language Pathology at Nova Southeastern University. She received her BA in psychology at Georgia State University and a minor in early childhood education. She has clinical experience working with pediatric dysphagia clients and has a strong desire to further her knowledge and clinical practice in this area to provide high-quality services to patients with dysphagia.

— Ashley V. Persaud is a student in the Master of Science in the Speech-Language Pathology program at Nova Southeastern University. She received her BA in liberal studies and triple minored in psychology, sociology, and business administration at the University of Houston. She received her graduate certificate in communication sciences and disorders from Florida International University. She has clinical experience working with dysphagia and a strong desire to further her knowledge and clinical practice in this area.

— Aislynn Barreto is a graduate student at Nova Southeastern University in the Master of Science in the Speech-Language Pathology program. She received her BS in health services administration at Florida International University. She has a distinct interest in furthering her knowledge on dysphagia.


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