Why do patients with hiatal hernia experience dizziness?

Why Patients with Hiatal Hernia Experience Dizziness

Dizziness in hiatal hernia patients is not a direct consequence of the hernia itself but rather results from medication side effects used to treat gastroesophageal reflux disease (GERD), particularly baclofen and proton pump inhibitors (PPIs), or from vagal nerve stimulation during reflux episodes.

Primary Mechanism: Medication-Induced Dizziness

The most common reversible cause of dizziness in hiatal hernia patients is medication side effects from GERD treatment. 1

Baclofen (GABA Agonist)

• Baclofen is used as add-on therapy to PPIs for refractory GERD symptoms in hiatal hernia patients 1
• Dizziness is a well-documented side effect of baclofen, along with somnolence, weakness, and trembling 1
• This medication decreases transient lower esophageal sphincter relaxations but carries significant central nervous system effects 1

Other GERD Medications

• Prokinetics (mosapride, itopride, domperidone) used in hiatal hernia management can cause dizziness as a side effect 1
• H2-receptor antagonists added to PPI therapy may contribute to dizziness in some patients 1

Secondary Mechanisms

Vagal Stimulation

• Hiatal hernias disrupt the normal anatomy of the gastroesophageal junction, leading to increased acid reflux episodes 2
• Severe reflux episodes can trigger vagal nerve stimulation, potentially causing transient dizziness or lightheadedness through cardiovascular effects 3
• This mechanism is more likely during acute reflux episodes with severe symptoms 1

Cardiovascular Considerations

• Patients on antihypertensive medications for comorbid conditions are at higher risk, as these drugs are a leading cause of medication-induced dizziness 3, 4
• The combination of GERD medications plus cardiovascular drugs increases dizziness risk 3

Clinical Approach to Evaluation

Medication Review (First Priority)

• Systematically review all medications, particularly baclofen, prokinetics, PPIs, antihypertensives, and sedatives 3, 4
• Medication side effects are the most common reversible cause of chronic dizziness 3
• Consider dose reduction or alternative GERD management strategies if baclofen is implicated 1

Distinguish True Vertigo from Lightheadedness

• Medication-induced dizziness typically presents as lightheadedness rather than true rotational vertigo 3, 4
• True vertigo suggests a vestibular disorder unrelated to the hiatal hernia 3
• Lightheadedness triggered by standing suggests orthostatic hypotension from medications 3, 4

Red Flags Requiring Urgent Evaluation

• Focal neurological deficits 3
• Sudden hearing loss 3
• Inability to stand or walk 3
• New severe headache 3
• Progressive neurologic symptoms 3

Management Strategy

If Baclofen-Related

• Discontinue or reduce baclofen dose and reassess symptoms within 1-2 weeks 1
• Consider alternative add-on therapies such as alginates, which do not cause dizziness 1
• H2-receptor antagonists may be substituted, though they have modest efficacy 1

If PPI-Related

• Switching to a different PPI may benefit some patients 1
• Optimize dosing and timing rather than discontinuing, as PPIs remain the cornerstone of GERD treatment 1

Surgical Consideration

• In patients with refractory GERD symptoms requiring multiple medications (including baclofen) who experience intolerable dizziness, laparoscopic fundoplication should be considered 1
• Surgery eliminates the need for baclofen and reduces PPI requirements, thereby resolving medication-induced dizziness 1
• The LOTUS trial showed 85% remission at 5 years with surgery versus 92% with medical therapy, but surgery avoids chronic medication side effects 1

Common Pitfalls

• Assuming dizziness is directly caused by the hiatal hernia itself rather than investigating medication side effects 3, 4
• Failing to perform a comprehensive medication review in patients with chronic dizziness 3
• Overlooking the temporal relationship between starting baclofen or increasing GERD medication doses and onset of dizziness 1, 3
• Not considering surgical options in patients with medication-intolerant refractory GERD 1