A hiatal hernia and aspiration pneumonia are distinct health issues that can become dangerously linked, particularly in individuals experiencing significant gastroesophageal reflux. A hiatal hernia involves the upper part of the stomach pushing through the diaphragm into the chest cavity. This anatomical defect compromises the body’s natural defenses against stomach contents moving backward, leading to chronic reflux. This severe reflux significantly increases the risk of inhaling stomach material into the lungs.
How Hiatal Hernia Contributes to Reflux
The body possesses a barrier at the junction of the esophagus and the stomach to prevent the backward flow of gastric acid. This natural barrier is formed by the lower esophageal sphincter (LES) and the diaphragm muscle that surrounds the esophagus at the hiatus. When the diaphragm contracts, it adds external pressure to the LES, reinforcing its function and helping to clamp down on the esophagus.
A hiatal hernia occurs when a portion of the stomach slides upward through the hiatus, displacing the LES into the chest cavity. This anatomical relocation separates the LES from the reinforcing pressure of the diaphragm. This displacement dismantles the two-part antireflux mechanism, causing the LES to lose the external squeeze necessary to maintain a high-pressure zone.
This mechanical defect results in an increased frequency and volume of reflux episodes, known as gastroesophageal reflux disease (GERD). The hernia also creates a pocket of gastric fluid that is difficult for the esophagus to clear. This prolongs the contact time of acid with the esophageal lining, and this chronic reflux sets the stage for the inhalation of stomach contents into the airways, known as aspiration.
The Process of Aspiration Pneumonia
Aspiration is the inhalation of foreign material, such as stomach contents, into the lower respiratory tract. When this material is highly acidic gastric refluxate, it triggers two distinct types of lung injury. The immediate and most damaging is chemical pneumonitis, which is a direct injury to the lung tissue caused by the caustic nature of stomach acid.
The inhalation of acidic fluid instantly damages the lining of the airways and alveoli, leading to acute inflammation, swelling, and fluid accumulation in the lungs. This chemical burn is a severe inflammatory reaction, not an infection, that can cause acute respiratory distress. Following this initial chemical damage, or when aspirating non-acidic contents, a secondary issue often arises.
Aspiration pneumonia involves an actual infection caused by bacteria inhaled along with the foreign material. These bacteria typically originate from the mouth or the stomach and colonize the lungs. When the body’s protective mechanisms are overwhelmed by the aspirate, the bacteria multiply, leading to infectious pneumonia. The resulting infection is often polymicrobial and can lead to complications such as lung abscesses if not treated swiftly.
Identifying Signs of Aspiration
Recognizing the signs of aspiration is important for individuals with hiatal hernias and persistent reflux. Acute aspiration events often present with sudden coughing or choking immediately after eating or lying down, sometimes accompanied by a feeling of fluid coming back up. However, many events, known as “silent aspiration,” may occur without a noticeable cough, especially during sleep.
The symptoms of resulting aspiration pneumonia include pulmonary-specific issues. A persistent, wet cough, which may produce foul-smelling, greenish, or dark phlegm, is a common finding, as is shortness of breath. Patients may also experience a fever and chills, indicating a systemic infection, along with chest pain and wheezing as the airways become inflamed.
Fatigue is a frequent complaint, particularly in older adults who are at a higher risk of silent aspiration. Since these symptoms overlap with other respiratory illnesses, individuals with known hiatal hernias or severe GERD must seek medical attention promptly if they experience a sudden or persistent change in respiratory health. A history of reflux combined with new pulmonary symptoms should prompt an investigation for aspiration-related disease.
Strategies to Minimize Aspiration Risk
Proactive lifestyle adjustments and medical management can significantly reduce the risk of aspiration in people with hiatal hernias and reflux. Elevating the head of the bed by six to eight inches, using blocks or a wedge pillow, utilizes gravity to keep stomach contents down. This prevents them from reaching the upper esophagus and throat during sleep.
Dietary and timing modifications are also helpful, such as avoiding large meals late in the evening and waiting at least two to three hours after eating before lying down. Maintaining an upright posture after meals aids in gastric emptying and reduces reflux potential. Specific foods and beverages that trigger relaxation of the LES or increase acid production should be limited:
- Alcohol
- Caffeine
- Chocolate
- Fatty foods
Medical treatments focus on reducing the volume and acidity of the refluxate. Proton pump inhibitors (PPIs) are commonly prescribed to decrease the amount of acid produced by the stomach cells, making any potential aspirate less caustic. Histamine-2 receptor blockers (H2 blockers) also decrease stomach acid production and may be used for less severe symptoms. For patients whose symptoms are not controlled by these methods, surgical repair of the hiatal hernia may be considered to address the underlying mechanical defect.