Hiatal Hernia

What is a hiatal hernia?

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.

What are the different hiatal hernia types?

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.

• Type 1: Type 1 — also called a sliding hiatal hernia — is by far the most common type, accounting for 95% of all hiatal hernias. In this version, the part of your esophagus that connects to your stomach slides up through the widened hiatus at times and then slides back down.
• Type 2: Types 2-4 are called paraesophageal hiatal hernias. “Paraesophageal” means “beside the esophagus.” In type 2, the upper part of your stomach pushes up through the hiatus alongside your esophagus, forming a bulge next to it. This is also called a rolling hiatal hernia.
• Type 3: Type 3 is a mix of the first two types. The part of your esophagus that connects to your stomach — the gastroesophageal junction — slides up through the hiatus at times. And another part of your stomach also bulges through, alongside the gastroesophageal junction at times.
• Type 4: Type 4 is rare, but it can be more complicated. In this version, the hiatus is wide enough for two different organs to herniate through it. The hernia involves your stomach together with another abdominal organ, such as one of your intestines, your pancreas or your spleen.

How common are hiatal 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.

What are hiatal hernia symptoms?

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:

• Heartburn. A burning sensation in your chest, especially after eating.
• Noncardiac chest pain. Recurring chest pain that feels like angina, but isn’t.
• Indigestion. Feeling full soon after eating, with a burning type of abdominal pain.
• Burping and regurgitation. Food, gas and acid rising back into your throat.
• Difficulty swallowing or a lump in your throat when you swallow.
• Sore throat and hoarseness when you speak, due to irritation from the acid.

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:

• Nausea, due to compression of your stomach or acid overflow, or both.
• Shortness of breath, if your hernia is compressing your lungs.
• Pressure or pain in your upper abdomen or your lower chest.

These symptoms are more likely with larger paraesophageal hernias.

What is hiatal hernia pain like?

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.

How does a hiatal hernia cause acid reflux?

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.

What causes a hiatal hernia?

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:

• Chronic coughing or sneezing.
• Chronic straining to poop (constipation).
• Chronic obesity (BMI, or body mass index, greater than 30).
• Frequent vomiting.
• Intense exercise or heavy lifting.
• Pregnancy and childbirth.

How serious is a hiatal hernia?

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.

What are the possible complications of a hiatal hernia?

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:

• Esophagitis: Acid in your esophagus causes inflammation of your esophagus lining. Chronic inflammation can cause pain, swallowing problems, ulcers and even bleeding.
• Esophageal stricture. Chronic inflammation can cause scarring of your esophagus tissues. Scar tissue can interfere with your swallowing muscles and cause your esophagus to narrow.
• Barrett’s esophagus. Chronic inflammation can also eventually lead to tissue changes called Barrett’s esophagus. This condition isn’t harmful by itself, but it’s considered precancerous.

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:

• Gastrointestinal obstruction. Your stomach or another organ could get stuck and compressed or twisted in the hiatus, creating a blockage in your gastrointestinal tract.
• Gastritis. Trapped acid in the herniated part of your stomach could cause inflammation, stomach ulcers and bleeding inside.
• Ischemia. Your hernia could become so tightly compressed that it cuts off its own blood supply. This leads to inflammation and pain in the organ and, eventually, tissue death.

How is a hiatal hernia diagnosed?

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:

• Chest X-ray. A chest X-ray or radiograph uses radiation to take still, black-and-white images of the inside of your chest cavity, where your esophagus lies.
• Esophagram. An esophagram is a sort of video X-ray of your esophagus in action. It takes real-time video of the inside of your esophagus when you swallow.
• Upper endoscopy. An upper endoscopy goes inside your esophagus and stomach with a tiny camera on the end of a long tube. It projects live images onto a screen.
• Esophageal manometry. This test uses a catheter inside your esophagus to take pressure measurements of the muscles. It converts the data into a topographical pressure map.

Do hiatal hernias go away?

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.

What is the medical treatment for a hiatal hernia?

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:

• Wait and watch. If your hernia isn’t bothering you, it might not need treatment. But your healthcare provider will want to keep an eye on it. It’s likely to get bigger over time.
• Use medications. Medications can’t stop acid reflux, but they can reduce the acid content in your stomach. This makes reflux less damaging and alleviates the pain associated with it.
• Surgery. A minor surgical procedure can repair your hiatal hernia. Surgery is an option for anyone, though not everyone will need it. Some people may need it sooner and others later.

Medications

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.

Surgery

Healthcare providers recommend hernia repair surgery when:

• Your hernia causes symptoms or complications that medications can’t prevent.
• The medications cause side effects that affect your health or quality of life.
• Your hernia is large enough to be a risk for major complications in the future.

Hiatal hernia surgery repairs the hernia and reflux by:

• Pulling your stomach and lower esophagus back under your diaphragm.
• Closing the hole in your diaphragm where the hernia came through.
• Tightening the junction between your stomach and your esophagus.

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.

What is recovery from hiatal hernia surgery like?

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).

How effective is surgery for a hiatal hernia?

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.

How can I treat my hiatal hernia at home?

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:

• Aim for a BMI that’s healthy for you. If overweight contributes to your reflux, losing weight could help.
• Eat smaller portions. Smaller meals reduce overall volume and pressure in your stomach.
• Eat less fat. Rich, fatty meals trigger more stomach acid and enzymes to help digest them.
• Eat dinner earlier. Avoid lying down for a few hours after eating to keep gravity on your side.
• Adjust your sleeping position. Elevating your head at night and sleeping on your left side can help prevent reflux when you sleep. A specially designed body pillow can help with this.
• Quit smoking. Smoking affects your lower esophageal sphincter muscle, making it weaker. It also can cause chronic coughing, which stresses the muscles around your hiatal hernia.

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.