Hiatal Hernia

What happens in a hiatal hernia

The esophagus passes through a gap in the diaphragm, the dome-shaped breathing muscle, to join the stomach. Normally the junction sits just below the diaphragm, where the diaphragm and the lower esophageal sphincter together prevent acid from flowing back.

When the hiatus widens and the supporting ligaments weaken, part of the stomach moves up into the chest. This weakens the anti-reflux barrier, and acid can also pool in the herniated pouch.

Types of hiatal hernia

Causes and risk factors

• Age: tissues weaken over time
• Increased pressure in the belly: obesity, pregnancy, chronic coughing, straining with constipation, heavy lifting
• Previous surgery around the esophagus or stomach
• Injury to the area
• Being born with a large hiatus
• Smoking

Symptoms

Small hiatal hernias usually cause no symptoms. Larger ones can cause:

• heartburn, especially after meals or lying down
• regurgitation of food or sour liquid
• belching and bloating
• chest pain or pressure, sometimes mistaken for heart pain
• difficulty swallowing or food sticking
• feeling full quickly
• shortness of breath after meals, if a large hernia presses on the lungs
• tiredness from iron-deficiency anemia caused by slow bleeding from ulcers in the herniated stomach (Cameron lesions)

Complications

• Gastroesophageal reflux disease and esophagitis
• Barrett's esophagus from long-term reflux
• Stricture: narrowing of the esophagus from scarring
• Anemia from chronic blood loss
• Gastric volvulus and strangulation: a paraesophageal hernia can twist, cutting off blood supply. This is a surgical emergency

Diagnosis

• Upper endoscopy: a camera examines the esophagus and stomach, shows the hernia and any inflammation, ulcers or Barrett's changes
• Barium swallow X-ray: shows the size and type of hernia
• CT scan: for large or complex hernias
• Esophageal manometry and pH testing: before surgery, to check esophageal muscle function and acid exposure

Hiatal hernias are often found by chance during tests for other reasons.

Treatment

Lifestyle changes

• eat smaller, more frequent meals
• stop eating 3 hours before lying down
• raise the head of your bed by 6 to 8 inches (15 to 20 cm)
• lose weight if you are overweight
• limit trigger foods and drinks that worsen your symptoms, commonly fatty or fried foods, alcohol, coffee, chocolate, mint, citrus, tomato and spicy foods
• stop smoking
• avoid tight clothing and bending after meals
• treat constipation to avoid straining

Hiatal hernia diet tips

There is no special diet that shrinks a hernia, but these choices help symptoms: lean proteins, vegetables, oatmeal, whole grains, bananas and melon, non-citrus fruits, low-fat dairy, water and herbal teas without peppermint.

Medicines

• Antacids and alginates for quick relief
• H2 blockers such as famotidine
• Proton pump inhibitors (PPIs) such as omeprazole for frequent symptoms and esophagitis
• Iron for anemia

Surgery

Surgery is considered for:

• large paraesophageal hernias, especially with symptoms
• reflux that does not respond to medicine, or people who do not want lifelong medication
• complications such as strictures, bleeding or volvulus

The usual operation is laparoscopic (keyhole) repair: the stomach is pulled back into the abdomen, the hiatus is tightened with stitches, sometimes reinforced with mesh, and a fundoplication wraps the top of the stomach around the lower esophagus to strengthen the valve. Most people go home within 1 to 2 days and follow a soft diet for a few weeks. Side effects can include temporary difficulty swallowing, bloating and difficulty belching. Hernias can recur over time.

Frequently asked questions

What are the symptoms of a hiatal hernia?

Small hernias often cause none. Larger ones cause heartburn, regurgitation, belching, chest discomfort, difficulty swallowing and feeling full quickly. Very large hernias can cause breathlessness after meals or anemia from slow bleeding.

What causes a hiatal hernia?

It is caused by weakening of the muscle and tissues around the opening in the diaphragm, together with pressure in the belly. Age, obesity, pregnancy, chronic cough, straining and heavy lifting increase the risk.

Can a hiatal hernia heal on its own?

No. A hiatal hernia does not go back on its own, but symptoms can usually be controlled with lifestyle changes and medicine. Losing weight may reduce reflux. Surgery is the only way to repair the hernia itself.

Is a hiatal hernia dangerous?

Most are not. Small sliding hernias are common and harmless apart from reflux. Large paraesophageal hernias can occasionally twist or trap the stomach, which is an emergency, so they are often repaired. Long-term untreated reflux can damage the esophagus.

What should I avoid with a hiatal hernia?

Avoid large meals, eating within 3 hours of bed, lying down after eating, tight clothing, smoking and heavy lifting. Common trigger foods include fried and fatty foods, alcohol, coffee, chocolate, mint, citrus, tomatoes and spicy foods.