Hiatal Hernia

Overview

A hiatal hernia occurs when the upper part of the stomach bulges through the large muscle separating the abdomen and chest (diaphragm). The diaphragm has a small opening (hiatus) through which the esophagus passes before connecting to the stomach. In a hiatal hernia, the stomach pushes up through that opening and into the chest cavity. This condition is one of the most common types of hernias and can affect people of all ages, though it's more prevalent in individuals over 50.

There are two main types of hiatal hernias. The most common type, sliding hiatal hernia (Type I), accounts for about 95% of cases. In this type, the gastroesophageal junction and a portion of the stomach slide up into the chest through the hiatus. This type may slide back and forth between the chest and abdomen. The second type, paraesophageal hernia (Types II-IV), is less common but potentially more serious. In this type, part of the stomach pushes through the diaphragm and stays there, while the gastroesophageal junction remains in its normal position.

Many people with hiatal hernia experience no symptoms and may never know they have the condition unless it's discovered during testing for another problem. However, larger hernias can cause significant symptoms, particularly related to gastroesophageal reflux disease (GERD). The prevalence of hiatal hernia increases with age, affecting up to 60% of individuals over age 60. While small hiatal hernias rarely cause problems, large hernias can lead to serious complications including severe GERD, esophagitis, and in rare cases, strangulation of the herniated portion of the stomach.

Symptoms

Many people with hiatal hernia have no symptoms at all, especially with small hernias. When symptoms do occur, they're often related to acid reflux and can vary in severity depending on the size and type of hernia.

Common Digestive Symptoms

Chest and Breathing Symptoms

Additional Symptoms

• Early satiety: Feeling full after eating only small amounts
• Nausea: Especially after meals
• Vomiting: In severe cases or with obstruction
• Bad breath: From regurgitated stomach contents
• Chronic cough: Due to acid irritating airways
• Hoarseness: From acid affecting vocal cords
• Sore throat: Chronic irritation from reflux

Emergency Symptoms

Seek immediate medical attention for:

• Severe chest or upper abdominal pain
• Inability to swallow
• Persistent vomiting
• Black or bloody stools
• Vomiting blood
• Signs of shock (rapid pulse, dizziness, cold sweats)

Symptom Patterns

• Positional symptoms: Worse when lying down, bending over, or straining
• Meal-related: Symptoms often worse after large meals
• Time of day: Often worse at night when lying flat
• Activity-related: May worsen with physical exertion

Causes

Hiatal hernia occurs when weakened muscle tissue allows the stomach to bulge through the diaphragm. The exact cause isn't always clear, but several factors contribute to the development of this condition.

Primary Causes

• Age-related changes:
  • Weakening of the diaphragm muscle over time
  • Loss of elasticity in supporting tissues
  • Deterioration of the phrenoesophageal membrane
  • Changes in the angle between esophagus and stomach
• Increased abdominal pressure:
  • Persistent coughing or sneezing
  • Straining during bowel movements
  • Heavy lifting repeatedly
  • Violent vomiting
  • Pregnancy (multiple pregnancies increase risk)
• Congenital factors:
  • Born with unusually large hiatus
  • Congenital shortened esophagus
  • Developmental abnormalities of the diaphragm

Contributing Factors

• Obesity:
  • Increased intra-abdominal pressure
  • Fatty tissue weakening the hiatus
  • Changes in gastroesophageal anatomy
• Trauma or injury:
  • Blunt trauma to the abdomen
  • Previous surgery in the area
  • Penetrating injuries
• Lifestyle factors:
  • Smoking (weakens lower esophageal sphincter)
  • Poor posture
  • Tight clothing around waist

Anatomical Factors

• Weakness in the phrenoesophageal ligament: The connective tissue anchoring the esophagus
• Widening of the muscular hiatus: The diaphragmatic opening enlarges
• Increased esophageal shortening: Due to chronic inflammation or scarring
• Loss of the acute angle of His: The angle between esophagus and stomach

Risk Factors

Several factors increase the likelihood of developing a hiatal hernia:

Non-Modifiable Risk Factors

• Age: Risk increases significantly after age 50
• Gender: Women are slightly more affected than men
• Genetics: Family history of hiatal hernia
• Ethnicity: More common in Western populations
• Body structure: Tall, thin individuals may have higher risk

Modifiable Risk Factors

• Obesity:
  • BMI over 30 significantly increases risk
  • Abdominal obesity particularly problematic
  • Weight fluctuations can worsen condition
• Smoking:
  • Weakens lower esophageal sphincter
  • Increases coughing (raising abdominal pressure)
  • Impairs tissue healing
• Physical strain:
  • Occupations requiring heavy lifting
  • Intense abdominal exercises
  • Chronic constipation with straining

Medical Conditions

• Connective tissue disorders: Ehlers-Danlos syndrome, Marfan syndrome
• Chronic lung disease: COPD, chronic bronchitis causing coughing
• Ascites: Fluid in abdomen increasing pressure
• Previous gastroesophageal surgery: May alter anatomy
• Scleroderma: Affects esophageal function

Lifestyle Factors

• Large meal portions
• Eating close to bedtime
• Tight clothing or belts
• Poor posture, especially slouching
• Frequent bending or stooping

Diagnosis

Hiatal hernia is often discovered incidentally during tests for other conditions. When symptoms suggest a hiatal hernia, several diagnostic methods can confirm the diagnosis and assess its severity.

Medical History and Physical Exam

• Symptom assessment:
  • Heartburn frequency and severity
  • Difficulty swallowing patterns
  • Positional symptoms
  • Response to antacids
• Physical examination:
  • Usually normal in most cases
  • May note epigastric fullness
  • Bowel sounds in chest (large hernias)
  • Signs of complications

Imaging Studies

• Barium swallow (Upper GI series):
  • X-rays after drinking barium contrast
  • Shows stomach position and hernia size
  • Evaluates esophageal function
  • Can detect complications
• Chest X-ray:
  • May show air-fluid level behind heart
  • Large hernias visible as mass
  • Often first clue to diagnosis
• CT scan:
  • Detailed anatomy visualization
  • Assesses hernia contents
  • Evaluates complications
  • Useful for complex cases

Endoscopic Evaluation

• Upper endoscopy (EGD):
  • Direct visualization of hernia
  • Assesses esophageal damage
  • Rules out Barrett's esophagus
  • Can detect complications
  • Allows tissue biopsy if needed

Functional Studies

• Esophageal manometry:
  • Measures esophageal muscle contractions
  • Assesses lower esophageal sphincter function
  • Important before surgery
• 24-hour pH monitoring:
  • Measures acid exposure in esophagus
  • Correlates symptoms with reflux
  • Helps plan treatment
• Impedance testing:
  • Detects non-acid reflux
  • More comprehensive than pH alone

Classification

• Type I (Sliding): 95% of cases, GE junction migrates
• Type II (Paraesophageal): Fundus herniates, GE junction normal
• Type III (Mixed): Features of both Type I and II
• Type IV (Complex): Other organs herniate (colon, spleen)

Treatment Options

Treatment for hiatal hernia depends on the severity of symptoms and the type of hernia. Many people with small hernias need no treatment, while others require medical management or surgery.

Lifestyle Modifications

• Dietary changes:
  • Eat smaller, more frequent meals
  • Avoid trigger foods (spicy, fatty, acidic)
  • Don't eat 3-4 hours before bedtime
  • Limit caffeine and alcohol
  • Stay upright after eating
• Weight management:
  • Lose excess weight gradually
  • Maintain healthy BMI
  • Avoid tight clothing
• Positional changes:
  • Elevate head of bed 6-8 inches
  • Use wedge pillow
  • Sleep on left side
  • Avoid bending after meals
• Habit modifications:
  • Quit smoking
  • Manage stress
  • Avoid straining
  • Practice good posture

Medical Management

• Antacids:
  • Quick symptom relief
  • Neutralize stomach acid
  • Use as needed for mild symptoms
• H2 receptor blockers:
  • Reduce acid production
  • Examples: famotidine, ranitidine
  • Good for mild to moderate symptoms
• Proton pump inhibitors (PPIs):
  • Most effective acid suppression
  • Examples: omeprazole, esomeprazole
  • Heal esophageal inflammation
  • Long-term use requires monitoring
• Prokinetic agents:
  • Improve esophageal motility
  • Enhance stomach emptying
  • Limited use due to side effects

Surgical Treatment

Surgery is reserved for severe symptoms, complications, or medication failure:

• Indications for surgery:
  • Severe GERD unresponsive to medication
  • Large paraesophageal hernias
  • Complications (bleeding, obstruction)
  • Severe esophagitis or stricture
  • Respiratory symptoms from reflux
• Laparoscopic Nissen fundoplication:
  • Most common procedure
  • Wraps stomach around esophagus
  • Repairs diaphragm defect
  • 85-95% long-term success rate
• Other surgical options:
  • Partial fundoplication (Toupet, Dor)
  • Gastropexy (stomach fixation)
  • Hernia sac excision
  • Mesh repair for large defects
• Post-surgical care:
  • Liquid diet initially
  • Gradual diet progression
  • Avoid carbonated beverages
  • Small meals permanently

Emerging Treatments

• Magnetic sphincter augmentation (LINX device)
• Transoral incisionless fundoplication (TIF)
• Endoscopic suturing techniques
• Radiofrequency therapy (Stretta)

Prevention

While not all hiatal hernias can be prevented, especially those due to congenital factors, many risk factors can be modified to reduce the likelihood of developing this condition:

Weight Management

• Maintain healthy weight:
  • Keep BMI below 30
  • Lose weight gradually if overweight
  • Focus on reducing abdominal fat
  • Avoid yo-yo dieting
• Exercise appropriately:
  • Regular moderate exercise
  • Avoid excessive abdominal exercises
  • Use proper lifting techniques
  • Strengthen core muscles safely

Reduce Abdominal Pressure

• Prevent constipation:
  • High-fiber diet
  • Adequate hydration
  • Regular exercise
  • Avoid straining
• Proper lifting technique:
  • Bend knees, not waist
  • Keep load close to body
  • Avoid holding breath
  • Get help with heavy objects
• Manage chronic cough:
  • Treat underlying conditions
  • Quit smoking
  • Control allergies
  • Avoid irritants

Dietary Habits

• Eat smaller, frequent meals
• Chew food thoroughly
• Avoid eating before bed
• Limit gas-producing foods
• Stay hydrated between meals
• Avoid trigger foods

Lifestyle Modifications

• Maintain good posture
• Wear loose-fitting clothes
• Manage stress effectively
• Avoid smoking and excessive alcohol
• Sleep with head elevated if prone to reflux

Medical Prevention

• Treat GERD promptly to prevent complications
• Regular check-ups if at high risk
• Manage chronic conditions that increase pressure
• Consider preventive measures before abdominal surgery

When to See a Doctor

While many people with hiatal hernia have mild or no symptoms, certain situations require medical evaluation:

Schedule an Appointment For:

• Persistent heartburn occurring more than twice a week
• Difficulty swallowing that doesn't improve
• Persistent nausea or vomiting
• Unexplained weight loss
• Chronic cough or hoarseness
• Feeling full quickly when eating
• Symptoms that interfere with daily activities
• Need for antacids more than 2-3 times per week

Seek Urgent Care For:

• Severe chest pain (rule out heart problems first)
• Inability to swallow liquids or solids
• Repeated vomiting, especially if bloody
• Black or bloody stools
• Severe abdominal pain and distension
• High fever with abdominal symptoms

Emergency Symptoms (Call 911):

• Sudden, severe chest or abdominal pain
• Signs of shock (rapid pulse, dizziness, cold sweats)
• Inability to pass gas or have bowel movements with pain
• Vomiting blood or coffee-ground material
• Severe shortness of breath

What to Discuss with Your Doctor:

• Complete symptom history and triggers
• Current medications and supplements
• Family history of hernias or GI problems
• Impact on quality of life
• Previous treatments tried
• Concerns about long-term complications

Related Conditions

References

1. Kohn GP, et al. Guidelines for the management of hiatal hernia. Society of American Gastrointestinal and Endoscopic Surgeons. Surgical Endoscopy. 2013;27(12):4409-4428.
2. Kahrilas PJ, et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterology & Motility. 2015;27(2):160-174.
3. Siegal SR, et al. Modern diagnosis and treatment of hiatal hernias. Langenbeck's Archives of Surgery. 2017;402(8):1145-1151.
4. Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ. 2014;349:g6154.
5. Sfara A, Dumitrascu DL. The management of hiatal hernia: an update on diagnosis and treatment. Medicine and Pharmacy Reports. 2019;92(4):321-325.
6. American Gastroenterological Association. Medical Position Statement on the Management of Gastroesophageal Reflux Disease. Gastroenterology. 2020;135(4):1383-1391.