What helps during a hiatal hernia attack?

Management of Acute Hiatal Hernia Attack

For acute symptomatic episodes of hiatal hernia, immediate relief involves elevating the head of bed, taking alginate-based antacids (such as Gaviscon) to displace the postprandial acid pocket below the diaphragm, and using PPI therapy 30-60 minutes before meals if not already on treatment. 1

Immediate Symptom Relief Measures

Positional and Mechanical Interventions

• Elevate the head of the bed by 15-20 cm immediately to reduce reflux and mechanical pressure from the herniated stomach. 1
• Avoid lying flat for at least 3 hours after eating, as this prevents supine reflux episodes that commonly trigger acute symptoms. 1, 2
• Sit upright or stand during acute episodes to allow gravity to assist in reducing gastric contents back into the abdomen. 1

Alginate-Based Antacids (First-Line for Acute Episodes)

• Alginate antacids (e.g., Gaviscon) are particularly effective for hiatal hernia patients during acute attacks because they form a physical raft that localizes and displaces the postprandial acid pocket below the diaphragm, directly addressing the mechanical component of hiatal hernia. 1
• These agents neutralize acid while creating a barrier, making them superior to standard antacids for breakthrough symptoms in patients with known hiatal hernia. 1, 2
• Use immediately when symptoms begin, especially after meals or at nighttime when symptoms are most severe. 1

Acid Suppression Therapy

• If not already on PPI therapy, take omeprazole 20 mg or equivalent PPI 30-60 minutes before meals to reduce acid burden during the acute episode. 1, 3
• For patients already on single-dose PPI with breakthrough symptoms, consider escalating to twice-daily dosing (before breakfast and dinner). 1, 2
• H2 receptor antagonists can be added at nighttime for nocturnal breakthrough symptoms, though effectiveness is limited by tachyphylaxis with repeated use. 1

Pain and Nausea Management

Symptomatic Treatment

• Narcotic medications may be necessary for severe pain control during acute episodes, particularly if there is significant gastric distension or incarceration. 1
• Critical pitfall: Avoid chronic use of potent narcotics (fentanyl patches, oxycodone) due to addiction risk in patients with recurrent attacks. 1
• Antiemetics should be used for nausea and vomiting associated with acute episodes. 1
• Aggressive intravenous hydration may be needed if there is significant third-space fluid sequestration, particularly with large hernias. 1

Dietary Modifications During Acute Phase

• Consume only small, frequent meals rather than large meals that increase gastric volume and pressure. 1
• Avoid trigger foods that worsen reflux (fatty foods, chocolate, caffeine, alcohol, acidic foods) during the acute episode. 1
• Maintain upright position for 3 hours after any food intake. 1, 2

When to Seek Emergency Care

Red Flag Symptoms Requiring Immediate Evaluation

• Severe, unrelenting epigastric or chest pain may indicate gastric volvulus or strangulation, which requires urgent surgical intervention. 4
• Inability to swallow liquids or saliva suggests complete obstruction. 4
• Hematemesis or melena indicates bleeding that requires immediate endoscopic evaluation. 1
• Progressive dysphagia with inability to pass food suggests incarceration or severe esophagitis requiring urgent assessment. 5

Ongoing Management After Acute Episode

Optimization of Medical Therapy

• After the acute episode resolves, ensure PPI is taken 30-60 minutes before the first meal of the day for optimal acid suppression. 1, 2, 3
• If symptoms recur despite single-dose PPI, escalate to twice-daily dosing or switch to a more potent PPI (esomeprazole, rabeprazole, or dexlansoprazole). 1, 2
• Patients with large hiatal hernias and erosive esophagitis grade B or higher require indefinite PPI therapy without dose reduction. 1, 2

Adjunctive Pharmacotherapy Based on Symptom Pattern

• For regurgitation-predominant symptoms, baclofen (a GABA-B agonist) can reduce transient lower esophageal sphincter relaxations, though CNS side effects (somnolence, dizziness) often limit use. 1, 2
• Prokinetics (mosapride, itopride, domperidone where available) have modest effect but may help if concomitant gastroparesis is present. 1
• Avoid metoclopramide due to risk of tardive dyskinesia and limited efficacy in GERD. 2

Weight Management and Lifestyle Optimization

• Aggressive weight loss is essential for overweight/obese patients, as central obesity increases intra-abdominal pressure and worsens hiatal hernia symptoms. 1, 5, 2
• Maintain head of bed elevation permanently, not just during acute episodes. 1, 5
• Avoid meals within 3 hours of bedtime as a permanent lifestyle modification. 1, 5, 2

Evaluation for Refractory Symptoms

Diagnostic Workup if Attacks Persist

• Upper endoscopy should be performed after 4-8 weeks of optimized medical therapy if symptoms persist, to assess for erosive esophagitis, stricture, or Barrett's esophagus. 1, 2
• 24-hour pH-impedance monitoring (off PPI) can quantify acid exposure and determine if symptoms correlate with reflux episodes. 1, 2
• Esophageal manometry is necessary before considering surgical intervention to assess peristaltic function and exclude achalasia. 2

Surgical Considerations

• Surgery should be considered for patients with recurrent acute episodes despite optimized medical therapy, but only after objective documentation of pathologic GERD. 1, 2
• Laparoscopic fundoplication is the standard surgical approach for symptomatic hiatal hernia with proven GERD in experienced hands. 1, 6, 7
• Key surgical principles include: hernia sac excision, achieving 3 cm intra-abdominal esophageal length, crural closure with consideration of mesh reinforcement for defects >8 cm, and anti-reflux procedure. 6, 8
• Patients with severe GERD phenotype (Los Angeles C or D esophagitis, bi-positional reflux, extreme acid exposure with AET >12%, or large hiatal hernia) may require indefinite PPI therapy or surgical intervention. 1

Behavioral and Neuromodulatory Interventions

For Patients with Esophageal Hypersensitivity

• Low-dose tricyclic antidepressants can be considered for patients with esophageal hypervigilance or visceral hypersensitivity contributing to symptom burden. 1, 2
• Referral to behavioral therapist for cognitive behavioral therapy, esophageal-directed hypnotherapy, or diaphragmatic breathing exercises may benefit patients with functional overlay. 1, 2