Can a hiatal hernia cause long-term congestion and productive cough?

From the Guidelines

Yes, a hiatal hernia can cause long-term congestion and productive cough, primarily through a mechanism called laryngopharyngeal reflux (LPR), where stomach contents reflux up past the esophagus and into the throat and airways, as supported by the 2016 Chest guideline and expert panel report 1. This condition is sometimes called "silent reflux" because traditional heartburn symptoms may be absent.

Causes and Mechanisms

The relationship between reflux and cough is supported by several physiological observations, including the fact that acid infusion into the distal esophagus increases the frequency of coughing and cough reflex sensitivity 1. During carefully conducted reflux monitoring studies, approximately half of unselected patients with chronic cough exhibit a positive symptom association between cough and acid or weakly acidic reflux events.

Management and Treatment

Management typically includes lifestyle modifications such as:

• Elevating the head of the bed 6-8 inches
• Avoiding meals within 3 hours of bedtime
• Eliminating trigger foods like caffeine, alcohol, chocolate, and fatty or spicy foods Medications that may help include:
• Proton pump inhibitors (like omeprazole 20-40mg daily or pantoprazole 40mg daily) for 8-12 weeks
• H2 blockers (like famotidine 20mg twice daily)
• Alginate-based reflux suppressants after meals and at bedtime In severe cases that don't respond to conservative treatment, surgical repair of the hiatal hernia may be necessary to prevent ongoing respiratory symptoms, as suggested by the 2016 Chest guideline and expert panel report 1.

Diagnosis and Evaluation

The diagnosis of reflux-cough syndrome can be challenging, and the 2016 Chest guideline and expert panel report suggest that a diagnostic/therapeutic algorithm sequentially addressing causes of common cough, including symptomatic reflux, be used 1. The guideline also recommends that patients with suspected chronic cough due to reflux-cough syndrome undergo esophageal manometry and pH-metry with conventional methodology if they are being evaluated for surgical management or if there is strong clinical suspicion warranting diagnostic testing.

Key Recommendations

The 2016 Chest guideline and expert panel report provide several key recommendations for the management of chronic cough due to gastroesophageal reflux in adults, including:

• Using a published management guideline that initially considers the most common potential etiologies as well as symptomatic gastroesophageal reflux
• Recommending treatment that includes diet modification, head of bed elevation, and avoiding meals within 3 hours of bedtime
• Using proton pump inhibitors, H2-receptor antagonists, alginate, or antacid therapy sufficient to control symptoms in patients who report heartburn and regurgitation
• Evaluating patients with esophageal manometry and pH-metry with conventional methodology if they are being considered for surgical management or if there is strong clinical suspicion warranting diagnostic testing.

From the Research

Hiatal Hernia and Respiratory Symptoms

• A hiatal hernia can cause long-term congestion and productive cough due to the reflux of stomach acid into the esophagus, which can lead to inflammation and irritation of the respiratory tract 2.
• The presence of a hiatal hernia can predict delayed acid clearance in the distal and proximal esophagus, which can contribute to respiratory symptoms such as congestion and cough 3.
• Gastroesophageal reflux disease (GERD) symptoms, including cough and congestion, can persist or recur after hiatal hernia repair, especially if the hernia recurs 4, 5.

Mechanisms of Hiatal Hernia-Related Respiratory Symptoms

• The lower esophageal sphincter (LES) and diaphragm play a crucial role in preventing reflux, and a hiatal hernia can disrupt this mechanism, leading to increased acid reflux and respiratory symptoms 2.
• Transient LES relaxations, impaired esophageal motility, and gastroduodenal dysfunctions can also contribute to the development of respiratory symptoms in patients with a hiatal hernia 2.
• The size of the hiatal hernia can also impact the severity of respiratory symptoms, with larger hernias potentially leading to more severe symptoms 3.

Treatment and Management

• Anti-reflux mucosectomy (ARMS) has emerged as a promising treatment for proton pump inhibitor-refractory GERD with hiatal hernia, and may help alleviate respiratory symptoms such as congestion and cough 6.
• Proton pump inhibitor (PPI) use can mask symptoms of hiatal hernia recurrence, and should be reserved until patients develop recurrent symptoms and have undergone a diagnostic workup to rule out an anatomic cause for the symptoms 5.