A hiatal hernia happens when the top of your stomach bulges through an opening in your diaphragm. This is a very common condition, especially as you get older. It doesn’t always cause symptoms, but when it does, they’re usually related to acid reflux. Treatment is available for hiatal hernias that cause symptoms.
A hiatal hernia occurs when the top of your stomach pushes up through an opening in your diaphragm into your chest. Your diaphragm is the muscle barrier that separates your abdominal cavity from your chest cavity. A hernia is when any organ or tissue pushes through a weakness in the tissue barrier that normally contains it. Hernias are common, and hiatal hernias are among the most common types.
Hiatal hernias push through a preexisting weakness in your diaphragm — the opening where your esophagus passes through to connect to your stomach. Healthcare providers call this opening the esophageal hiatus, which is where the term, hiatal hernia, or hiatus hernia, comes from. Stress and strain can widen this opening over time. This condition usually develops slowly over many years.
There are two main types: sliding hiatal hernias and paraesophageal hiatal hernias. Most people have the sliding kind, which is type 1. All of the other three types are paraesophageal hernias.
Hiatal hernias are common, especially as you get older. In the U.S., they affect about 20% of the general population. They affect 50% over the age of 50, 60% over the age of 60 and 70% over the age of 70.
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If you only have a sliding hiatal hernia, which is what most people have, you probably won’t feel the hernia itself. Unlike other kinds of hernias, you probably won’t see the bulge from the outside, either.
Many people never have symptoms of hiatal hernias. But among those who do, the most common symptoms are related to chronic acid reflux (gastroesophageal reflux disease, or GERD). These include:
Not everyone with a hiatal hernia has acid reflux, and not everyone with acid reflux has a hiatal hernia. But if you’ve recently begun to notice these symptoms more often, they might be related.
Other possible warning signs of a hiatal hernia might include:
These symptoms are more likely with larger paraesophageal hernias.
Your hiatal hernia is located at the junction between your abdomen and your chest. If you feel pain from the hernia itself, it might feel like chest pain or abdominal pain. You might feel a hiatal hernia if it gets compressed or pinched during certain activities or positions. For example, bending over, coughing or lifting something heavy might affect a larger hiatal hernia. Pain might be a sign that it’s getting worse.
Most of the time, pain from a hiatal hernia is related to acid reflux rather than the hernia itself. Acid irritates your esophagus, which runs through your chest up to your throat. You may feel it higher or lower, or the pain may radiate throughout your chest. It may burn. For some people, it may even feel like a heart attack. If you’re in doubt, it’s always best to have chest pain checked out by a healthcare provider.
When the gastroesophageal junction — the place where your esophagus meets your stomach — rises above your diaphragm, it pulls some of the muscles that would normally contract to prevent acid reflux. When these muscles can’t tighten enough to close your esophagus effectively, stomach acid can wash back into it. The hernia also traps a pocket of acid at the top of your stomach that can’t clear away.
A hernia becomes possible when there’s a weak spot in the tissues that separate your different body compartments. That weak spot creates an opening for a hernia to come through. A hiatal hernia, in particular, comes through an opening that already exists: the esophageal hiatus, where your esophagus passes through your diaphragm. This opening only has to widen a little to make a hiatal hernia possible.
Sometimes a specific injury, surgery or even a birth defect causes the original weakness that creates a hernia. But more often, it’s cumulative damage from years of daily stress and strain. Anything that produces extra pressure in your abdominal cavity can wear on your diaphragm over time. Some of the most common forces that create abdominal pressure and contribute to hiatal hernias include:
Most aren’t serious. Most don’t even cause symptoms. You may never know that you have one. But a larger hernia could eventually become serious. You’d probably have symptoms if you had a larger one.
The most common problem that hiatal hernias cause is chronic acid reflux. Chronic acid reflux can do damage to your esophagus over time, if it’s severe and medications don’t manage it well enough.
Complications of chronic acid reflux can include:
More rarely, a hiatal hernia may cause complications if it gets stuck or compressed in the hiatus. This usually only happens with the less common types of hiatal hernias. Complications could include:
Healthcare providers find hiatal hernias by looking at images of your esophagus and stomach. Sometimes, they find it accidentally while looking for something else. If they’re looking for it, it’s usually because you have symptoms of acid reflux. They might begin with an esophageal pH test to confirm there’s acid in your esophagus. If there is, they’ll follow up with imaging tests to find out why.
Tests that can diagnose a hiatal hernia include:
Hernias don’t go away. They usually get worse over time. But that doesn’t mean your hernia will cause problems for you. If your hiatal hernia never causes any symptoms, you might not need to treat it. But if it does, you can expect those symptoms to continue and possibly worsen. You might be able to manage mild acid reflux with medications. But if you have a more severe case, you might need surgical repair.
Your healthcare provider will thoroughly evaluate the nature of your hernia, your reflux and your symptoms to help determine the best long-term treatment approach for you. The options are:
If you only have occasional reflux, you can treat it with over-the-counter (OTC) antacids. But if you have it more frequently, you’ll need a prescription for long-term, daily use. Healthcare providers usually prescribe proton pump inhibitors (PPIs) for this purpose. These effectively prevent and repair damage from acid in your esophagus. But they can’t stop regurgitation or stop your hernia from growing.
Healthcare providers recommend hernia repair surgery when:
Hiatal hernia surgery repairs the hernia and reflux by:
The procedure is called a fundoplication. This name refers to the upper part of your stomach, which is called the fundus. During the procedure, your surgeon wraps the fundus around your lower esophagus and attaches it with surgical staples or stitches. This tightens the muscle that separates the two organs (lower esophageal sphincter). When possible, they do this by minimally invasive laparoscopic surgery.
You may need to recover in the hospital for a day or two, depending on your condition and the type of surgery you had. Recovery is generally shorter and easier when you have laparoscopic surgery or robotic surgery for hernia repair. That’s because these methods use small, keyhole incisions instead of the larger incision needed for open surgery. But sometimes, the open approach is necessary.
You’ll continue to recover at home for another two to six weeks. During this period, while your surgery is healing, you won’t be able to eat normally due to temporary symptoms and side effects. Your provider will prescribe a very limited diet, beginning with clear liquids and gradually progressing to soft foods and, finally, solids. Weight loss after hiatal hernia surgery is common — typically 10 to 15 pounds (4.5 to 6.8 kilograms).
Hiatal hernia surgery has a 90% success rate. Most people are able to discontinue medications and enjoy life free of acid reflux after hiatal hernia surgery. You’ll have follow-up visits with your provider at least once a year after completing your recovery to check on your repaired hernia and make sure everything’s still working right. If any new problems develop or old problems return, they’ll be on the case.
In long-term studies, up to 50% of hiatal hernias eventually return after surgery, usually after many years. This might be because some part of the operation failed, or it might be because the original forces that caused the first hernia are still active, and they caused a new one. Not all recurring hernias will cause the same symptoms, however. But if they do, a new surgery can fix it, often permanently.
If you’re living with a hiatal hernia that causes occasional symptoms, you may be able to treat it at home with over-the-counter medications and lifestyle changes. Antacids — like Tums ®, Rolaids ® and Pepto-Bismol ® — can help neutralize occasional acid flare-ups, though you shouldn’t take them too often. Certain lifestyle changes may also help reduce the frequency and severity of your reflux. For example:
A note from Cleveland Clinic
You may discover a hiatal hernia incidentally while visiting a healthcare provider for another reason. They’re very common, and if yours is small and doesn’t bother you, it’s no cause for concern. Alternatively, you may discover a hiatal hernia after years of worsening symptoms finally bringing you to seek answers and relief. You may be surprised to learn that a hernia is the cause of your acid reflux.
Fortunately, both acid reflux and hiatal hernias are treatable. The treatment you need will depend on your hernia’s nature and symptoms. In many cases, medication and lifestyle changes are enough to manage acid reflux. In more severe cases, you may need surgery to repair the hernia. This surgery is very effective. Once your diagnosis is clear, you’ll be on your way to symptom relief.
Last reviewed by a Cleveland Clinic medical professional on 06/30/2023.
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