What causes dizziness in an older adult patient with a history of Gastroesophageal Reflux Disease (GERD) and a hiatal hernia?

Dizziness with Hiatal Hernia: Understanding the Relationship

Dizziness is not directly caused by hiatal hernia itself, but rather occurs through indirect mechanisms including severe GERD symptoms, vagal nerve stimulation, medication side effects (particularly PPIs and baclofen used for reflux), and the need to exclude other serious causes of dizziness in older adults with these conditions.

The Lack of Direct Causation

The available gastroenterology guidelines and research on hiatal hernia and GERD do not establish dizziness as a recognized symptom of hiatal hernia 1. Hiatal hernias are primarily associated with:

• Typical esophageal symptoms: Heartburn and regurgitation (70% sensitive and specific for GERD) 1
• Mechanical symptoms: Dysphagia, belching, and chest pain 1
• Abdominal complaints: Abdominal pain, which can have multiple causes including the hernia itself, constipation, or diverticulitis 1

Potential Indirect Mechanisms

Medication-Related Dizziness

If the patient is being treated for GERD associated with hiatal hernia, certain medications can cause dizziness:

• Baclofen (used as add-on therapy for refractory GERD): Explicitly causes dizziness as a common side effect, along with somnolence, weakness, and trembling 1
• Polypharmacy effects: Older adults on multiple medications for various conditions are at high risk for medication-induced dizziness 2, 3

Vagal Stimulation Theory

While not explicitly stated in the guidelines, severe reflux episodes or large hiatal hernias could theoretically stimulate vagal responses, though this mechanism is not validated in the provided evidence.

Critical Differential Diagnosis in Older Adults

The most important clinical action is to properly evaluate the dizziness itself, as it may represent a serious condition unrelated to the hiatal hernia 2, 4, 3:

Life-Threatening Causes to Exclude

• Stroke/TIA: 75-80% of stroke-related acute vestibular syndrome patients have no focal neurologic deficits, making it easy to miss 4
• Cardiovascular causes: Postural hypotension is extremely common in older adults, particularly those on multiple medications 2, 3

Common Benign Causes

• Benign paroxysmal positional vertigo (BPPV): The most common cause of vertigo in older adults, affecting 9% of elderly patients in geriatric clinics 2, 4
• Vestibular migraine: Accounts for up to 14% of vertigo cases with lifetime prevalence of 3.2% 2, 4

Clinical Approach

Essential History Questions

• Duration of episodes: Seconds suggest BPPV; minutes suggest stroke/TIA or vestibular migraine 3
• True vertigo vs. presyncope: Spinning sensation indicates inner ear dysfunction; feeling faint suggests cardiovascular causes 3
• Positional triggers: Head position changes trigger BPPV 3
• Medication review: Comprehensive review of all medications, especially diuretics, β-blockers, antipsychotics, and tricyclic antidepressants 3

Physical Examination Priorities

• Dix-Hallpike maneuver: To diagnose BPPV 3
• HINTS examination: 100% sensitivity for stroke when performed by trained practitioners 3
• Orthostatic vital signs: To detect postural hypotension 3
• Fall risk assessment: Dizziness increases fall risk 12-fold in elderly patients 3

Common Pitfalls to Avoid

• Never assume the hiatal hernia is causing the dizziness without thoroughly evaluating other causes 2, 4, 3
• Never rely solely on CT imaging for suspected stroke, as it frequently misses posterior circulation strokes 3
• Do not assume absence of focal neurologic deficits rules out stroke 4, 3
• Consider that up to 80% of stroke patients with acute vestibular syndrome may have no focal neurologic signs 4

Management Implications

If the dizziness is determined to be medication-related from GERD treatment:

• Consider discontinuing baclofen if being used for refractory GERD 1
• Review and optimize PPI dosing: Taper to lowest effective dose 1
• Address polypharmacy: Systematically review all medications 3

The hiatal hernia itself should be managed according to standard GERD protocols with lifestyle modifications, PPI therapy, and consideration for surgical repair only if symptomatic with mechanical obstruction or refractory reflux 1.