What is a hiatal hernia?
The diaphragm is the muscle that helps us breathe. It separates the chest from the belly.
Everyone has a natural opening in the diaphragm called the hiatus, which allows your food pipe (oesophagus) to connect to your stomach.
A hiatal hernia occurs when part of the stomach slides up into the chest through this opening.
Courtesy of Servier Medical Art
If the hernia is large, sometimes other organs, such as the intestines, can also move into the chest. This is known as a type 4 hiatal hernia and although it is less common, it can carry greater risks.
Why do I have a hiatal hernia?
There are usually several reasons why someone develop a hiatal hernia.
Some people are born with one, which means they have it from birth – this is called congenital. These hernias might not cause any symptoms until later in life.
For most people, a hiatal hernia develops because the opening in the diaphragm (hiatus) becomes weak and stretches over time, which is very common as we get older.
Along with this, the ligaments that hold the stomach in place also weaken, allowing it to slip into the chest.
Another main cause is increased pressure in the belly, which can push the stomach up through the hiatus.
This pressure can result from being overweight, having a long-lasting cough or constipation, and, less commonly, pregnancy. Even if these aren’t the main cause in your case, they can still make your symptoms worse.
Hiatal hernias can also occur after an injury, such as trauma or surgery near the diaphragm – for example, a car accident.
Finally, some people are naturally more susceptible to developing one due to a genetic predisposition.
What are the symptoms?
Some people may have no symptoms at all, while others might have several. This usually depends on how big the hiatus is and how much of the stomach has moved up into the chest.
The most common symptoms include:
- Reflux or heartburn
- Lower chest pain, especially after eating
- Vomiting
- Regurgitation (when food or acid comes back up after eating or while lying down)
- Food getting stuck – usually in the lower chest
- Feeling full or sick after smaller meals than usual
Less commonly, large hiatal hernias can press on the lungs or heart, which might cause:
- Irregular heartbeat (arrhythmia)
- Difficulty for the heart to fill with blood
- Breathlessness
Large hernias take up space in the chest and compete with your heart and/or lungs for room.
In some cases, a hernia can cause small ulcers, known as Cameron erosions. These form where the stomach rubs against the opening in the diaphragm (hiatus) which each breath.
These ulcers can bleed and cause anaemia.
Erosions in an endoscopy
From Lee, H.N., et.al. (2012). A Case of Cameron Ulcer Presenting with Melena. The Korean Journal of Internal Medicine, 82, 585-588.
These symptoms are quite common and can be caused by many different conditions.
Having one or more of these symptoms does not necessarily mean you have a hiatal hernia. However, if your symptoms are concerning or affecting your quality of life, speak with your doctor.
How is it diagnosed?
Quite often, a hiatal hernia is found by chance during an X-ray or CT done for another reason.
Normal Chest X-ray
Chest X-ray with hiatal hernia
A hiatal hernia can also be diagnosed with an endoscopy. You might have this procedure if you’re experiencing symptoms such as heartburn, tummy or chest pain, or to investigate the cause of anaemia.
During an endoscopy, a thin, flexible tube with a camera is gently passed down your throat to examine your oesophagus, stomach and the first part of your small intestine.
Will it go away on its own?
No, a hiatal hernia will not go away by itself. It usually stays the same or may get bigger over time.
What is the treatment?
It depends on the type of hernia you have and the severity of your symptoms. Many people experience reflux, which is when acid or food comes back up from the stomach into the food pipe (oesophagus).
Most patients need treatment for reflux. This often includes lifestyle changes and, in many cases, antiacid medications.
However, not everyone with reflux has a hiatal hernia and not everyone with a hernia has reflux.
Lifestyle and diet
Even if you don’t have heartburn, lifestyle modifications are still helpful. Other symptoms – such as bloating, feeling full quickly or discomfort after eating – happen because food has trouble passing through the narrowed hiatus. When the stomach is pushed into the chest, it can become difficult to empty, slowing digestion. To help prevent this:
- Keep a healthy weight. Extra body weight, especially fat around your organs, increases the pressure inside your belly. This pressure can push your stomach upward and make the hiatal hernia worse. Losing weight helps ease this pressure and can improve your symptoms.
- Chew your food well and eat slowly. This prevents your stomach from becoming too full, which is one of the causes of your symptoms.
- Eat smaller meals. Smaller portions help your stomach empty more easily and reduce the chance of food or acid coming back up.
- Eat at least 15 grams of fibre per day. Fibre supports digestion and helps prevent constipation. This lowers belly pressure and eases reflux and other symptoms.
- Wait 2 to 3 hours after eating before lying down. This gives your body time to start digesting and lets gravity help move food through your stomach.
- Avoid high-calorie and high-fat diets. These slow digestion and worsen reflux.
- Sleep with the head of the bed elevated. You can use a wedge pillow or place bricks or books under the top legs of the bed. Raising the head of the bed 10–15 cm is usually enough.
- Sleep on your left side. This position helps keep stomach contents lower, making reflux less likely.
Avoid eating processed and ‘diet’ foods, especially those containing the artificial sweetener aspartame. Aspartame contains phenylalanine, which can worsen reflux and make your body more sensitive to even small amounts of stomach acid.
Calcium supplements can have a similar effect, so it’s best to avoid them unless you have a genuine deficiency. If your doctor has prescribed them and you are still experiencing reflux despite a healthy diet and lifestyle changes, speak with your GP about the best options for you.
Medication
Antiacid tablets are available and often helpful, but the first and most important step in treatment is changing your diet and lifestyle.
When these changes aren’t enough, your doctor may prescribe acid-reducing medications like Omeprazole, Rabeprazole or similar.
These treatments don’t fix the hernia, but can greatly reduce your symptoms
Is surgery an option?
Yes, surgery is the only way to repair the hernia, but it carries risks and isn’t the right choice for everyone. Whether it’s right for you should be discussed with your surgeon.
Things your surgeon will consider include the type of hernia you have, its size, how severe your symptoms are, if you’ve had abdominal surgery before and whether you have any other health conditions that could increase your surgical risks.
The main goal of surgery is to improve your quality of life and help prevent complications.
Surgery is usually recommended if:
- Your symptoms continue despite sticking to dietary changes, lifestyle modifications and medical treatment
- Your hernia is causing serious issues such as obstruction, bleeding or affecting your lung or heart function
What happens during the operation?
These days, most operations are done using a keyhole technique or laparoscopy. This means the surgeon makes few small cuts in your belly and uses a camera and long instruments to perform the surgery. This method usually means less pain and a quicker recovery compared to open surgery.
To give the surgeon some room to work safely, your belly is gently inflated with gas (carbon dioxide CO₂). This is called pneumoperitoneum.
During the operation, the organs that have moved up into your chest- most often the stomach – are carefully pulled back into your belly. Then, the opening in the diaphragm where the stomach slipped through (hiatus) is tightened with stitches to close the gap. This is called cruroplasty.
In many cases, your surgeon will also perform a procedure called a fundoplication.
This involves wrapping the top part of the stomach around the bottom of the food pipe (oesophagus). This helps prevent reflux after surgery. Simply putting the organs back isn’t always enough – especially if the hernia has been there for a long time or if reflux is the main symptom – particularly in patients with small hernias.
The wrap also helps secure the stomach in place around the diaphragm, reducing the chances of the hernia coming back.
There are many types of fundoplication, depending on how much of the circumference of the oesophagus is wrapped.
Your surgeon will determine the most suitable type, based on your symptoms, hernia type and individual circumstances.
What to expect after elective surgery?
After your operation, you usually stay in hospital for 1–2 nights to ensure you can tolerate food and that there are no complications.
You can typically drink right away. Solid foods are usually introduced gradually after a few days, although most surgeons recommend sticking to pureed foods for about two weeks.
Most people recover quickly and can eat almost any food within 3–4 weeks.
If you’ve had a hernia for a long time, your food pipe (oesophagus) may not empty well, so it’s important to progress your diet carefully.
If you had a wrap (fundoplication), there may be swelling in the lower oesophagus, which can make food feel like it’s getting stuck. Most of the time, this is temporary, but it can make emptying feel more difficult
It’s important to follow your surgeon’s and dietitian’s advice when moving to solid foods and to eat mindfully – chewing well and taking small portions are vital.
After surgery, some people, especially those who had a fundoplication, may experience gas-bloating syndrome, which can cause bloating and increased flatulence.
This is a secondary effect of the operation, but symptoms can usually be reduced by eating slowly, chewing well, taking small portions, avoiding gas-forming foods, not talking too much during meals and not using straws, as these habits can introduce more gas into your stomach and make your symptoms worse.
Occasionally, reflux or the feeling of food sticking (dysphagia) can persist. Despite careful management, some people may have lifelong difficulties tolerating certain foods, such as steak or soft bread, or their reflux may not be completely controlled. It’s important to discuss your individual risks with your surgeon.
If you had significant inflammation from reflux (oesophagitis) before your surgery, it may take a little longer for your symptoms to settle. In some cases, your surgeon may recommend continuing antacid tablets for a few weeks, but for most people, the operation works immediately and antacids can usually be stopped from day one.
Surgery in a hurry: when and why?
Usually, the part of the stomach that has moved into the chest shifts slightly up and down as you breathe.
In some cases, the hernia can get stuck in the chest – this is called incarceration. If not treated quickly, it can cut off the blood supply to the stomach, putting you at serious risk.
Large hiatal hernias can also cause a twist in the stomach, a condition called volvulus. This twisting can also affect the blood vessels to the stomach, cutting its blood supply.
These situations are rare, but can be serious and usually require emergency surgery. If your surgeon thinks you’re at high risk, an operation may be the best way to prevent these complications.
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