Hiatal hernia

A hiatal hernia occurs when part of the stomach pushes upward through the diaphragm into the chest through the opening (hiatus) where the esophagus normally passes. The most common type is a sliding hiatal hernia, in which the gastroesophageal junction and a portion of the stomach slide up. A paraesophageal hernia, in which part of the stomach moves up beside the esophagus, is less common but more prone to complications.

Many hiatal hernias cause no symptoms and are found incidentally. When symptoms occur, they are often related to gastroesophageal reflux (heartburn, regurgitation). Treatment focuses on reflux management; surgery is reserved for large or complicated hernias and for reflux that does not respond to medical therapy.

Many people have no symptoms. When present, symptoms may include:

• Heartburn
• Regurgitation of food or sour liquid
• Difficulty swallowing
• Chest or abdominal pain
• Feeling full soon after eating
• Shortness of breath (with large hernias)
• Vomiting of blood or passing black stools (if bleeding occurs from associated esophagitis or ulcers)

Severe chest or abdominal pain, inability to swallow, vomiting that will not stop, or signs of bleeding require urgent evaluation — possible complications of a paraesophageal hernia include strangulation or obstruction.

A hiatal hernia develops when the supporting tissues around the esophageal hiatus weaken or stretch, allowing the stomach to herniate upward. Contributing factors include age-related changes, increased abdominal pressure (obesity, pregnancy, chronic cough, straining), prior surgery or injury, and congenital variations in diaphragmatic structure. The exact reason some people develop symptoms and others do not is not fully understood; the hernia facilitates reflux but is not the sole cause of GERD.

Risk factors include:

• Age 50 and older
• Obesity
• Pregnancy
• Chronic cough or chronic constipation (repeated straining)
• Heavy lifting
• Smoking
• Prior abdominal or esophageal surgery in some cases

Possible complications include:

• Severe GERD and erosive esophagitis
• Barrett’s esophagus and elevated esophageal cancer risk from chronic reflux
• Esophageal stricture from scarring
• Ulceration and bleeding
• For paraesophageal hernias: gastric volvulus, obstruction, ischemia, or strangulation (surgical emergencies)
• Iron-deficiency anemia from chronic blood loss
• Respiratory symptoms from large hernias

Not all hiatal hernias can be prevented. Helpful measures include maintaining a healthy weight, avoiding heavy lifting with breath-holding, treating chronic cough and constipation, and not smoking. Reflux lifestyle measures reduce symptom burden even when a hernia is present.

Diagnosis may involve:

• Upper endoscopy (EGD) — visualizes the hernia, esophagitis, and complications; allows biopsy
• Barium swallow X-ray
• Esophageal manometry and pH or pH-impedance testing when surgery for reflux is considered
• CT scan in acute settings when complications are suspected

Small sliding hernias are extremely common and may not explain all symptoms; correlation with reflux testing is important before major interventions.

See a clinician for frequent heartburn, regurgitation, difficulty swallowing, or unexplained chest pain. Seek emergency care for severe chest or abdominal pain, persistent vomiting, inability to pass gas or stool, or vomiting blood / black stools.

Treatment is guided by symptoms and hernia type:

Lifestyle measures

• Weight loss if overweight
• Elevate the head of the bed
• Avoid late meals and trigger foods
• Stop smoking
• Eat smaller meals

Medications

• Proton-pump inhibitors (PPIs) or H2 blockers for reflux-related symptoms
• Antacids for breakthrough symptoms

Surgery

• Considered for large paraesophageal hernias, acute complications, or refractory GERD with confirmatory testing
• Typically involves hernia reduction, hiatal closure, and fundoplication (e.g., Nissen or partial wrap), often laparoscopic
• Emergency surgery for strangulation or acute obstruction

Daily strategies:

• Take reflux medicines as prescribed
• Maintain healthy weight and avoid tight clothing around the abdomen
• Do not lie down within 2–3 hours after eating
• Elevate the head of the bed on blocks (pillows alone are less effective)
• Chew thoroughly and eat slowly
• Report difficulty swallowing, unintentional weight loss, or bleeding symptoms promptly

Bring:

• Symptom pattern (heartburn, regurgitation, swallowing difficulty, timing with meals)
• List of medicines including over-the-counter antacids and PPIs
• Prior endoscopy or X-ray reports
• Questions about need for surgery versus continued medical therapy