Hiatal Hernia
A hiatal hernia is a condition in which part of the stomach pushes up through the diaphragm into the chest through an opening called the hiatus, which normally allows only the esophagus to pass between the chest and abdomen. Hiatal hernias are very common, particularly in adults over age 50, and many cause no symptoms. When symptoms occur, they most often include heartburn, reflux, and chest or upper abdominal discomfort. Larger or more complex hernias may require closer evaluation and, in some cases, surgical treatment.
What is it?
The diaphragm is the dome-shaped muscle that separates the chest from the abdomen and serves as the main muscle of breathing. It has a small opening called the esophageal hiatus, through which the esophagus normally passes on its way from the chest down to the stomach. In a hiatal hernia, part of the stomach—and sometimes other abdominal structures—pushes upward through this opening into the chest.
There are several types of hiatal hernia. The most common, by far, is the sliding (type I) hiatal hernia, in which the junction between the esophagus and stomach slides up into the chest. This type is often associated with gastroesophageal reflux disease (GERD), because it can weaken the natural barrier that normally prevents stomach contents from flowing backward into the esophagus. Paraesophageal hernias (types II, III, and IV) are less common but more clinically important; in these, part of the stomach—or, occasionally, other abdominal organs—pushes up alongside the esophagus, sometimes leaving the esophagus-stomach junction in its normal position. Large paraesophageal hernias can occasionally rotate (volvulus) or become incarcerated or strangulated, which is a surgical emergency.
The exact cause of hiatal hernias is not always clear. Factors that increase risk include age (the supporting tissues around the hiatus weaken over time), obesity, pregnancy, chronic coughing, repeated heavy lifting, prior surgery in the area, and certain congenital factors. Smoking and excessive alcohol use may worsen reflux symptoms, even though they don’t directly cause the hernia.
Many people with hiatal hernias have no symptoms and learn about the diagnosis incidentally on imaging done for other reasons. When symptoms occur, they often relate to reflux of stomach contents into the esophagus and may include heartburn, regurgitation of food or sour liquid, a burning sensation behind the breastbone, chest or upper abdominal discomfort, difficulty swallowing, hoarseness, sore throat, chronic cough, or worsening of asthma. Large hernias—particularly paraesophageal hernias—can cause additional symptoms such as early fullness with meals, nausea, vomiting, shortness of breath (especially after eating), and, in severe cases, symptoms of obstruction.
Hiatal hernias are often visible on chest X-rays, particularly when large, sometimes appearing as an air- or fluid-filled structure behind the heart. CT of the chest and upper abdomen provides detailed anatomical information about the size and type of hernia and the structures involved. Upper gastrointestinal (barium swallow) studies show the relationship between the stomach and diaphragm in real time. Upper endoscopy directly visualizes the esophagus and stomach and is particularly important when symptoms suggest reflux disease or complications such as esophagitis or Barrett’s esophagus. In selected cases, esophageal manometry and pH testing help characterize esophageal function and reflux severity.
Important to Know
Treatment of a hiatal hernia depends on its size, type, and the symptoms it causes. Many small, asymptomatic sliding hernias do not require specific treatment beyond addressing reflux symptoms if they occur. Lifestyle measures—such as eating smaller meals, avoiding eating close to bedtime, elevating the head of the bed, weight loss, avoiding tight clothing, limiting alcohol and tobacco, and identifying personal trigger foods—can substantially improve reflux symptoms. Medications such as antacids, H2 blockers, and proton pump inhibitors are commonly used to reduce stomach acid and manage symptoms.
Surgical repair is generally considered for large or symptomatic paraesophageal hernias, hernias with significant ongoing symptoms despite optimal medical therapy, and, urgently, for hernias complicated by obstruction, strangulation, or volvulus. Surgery typically involves repositioning the stomach back into the abdomen, repairing the diaphragmatic opening, and often performing an anti-reflux procedure (such as a fundoplication). Most operations are now performed using minimally invasive techniques.
Care is typically coordinated by primary care clinicians, gastroenterologists, and surgeons. Imaging findings are interpreted together with symptoms, endoscopic findings, and the patient’s overall health.
Red flag symptoms include sudden severe chest or upper abdominal pain, persistent vomiting, inability to keep food or liquids down, vomiting blood, black or tarry stools, difficulty breathing, signs of obstruction (bloating, severe cramping, no passage of stool or gas), or chest pain that mimics a heart attack. These warrant urgent medical evaluation, as they may indicate a complication of a hiatal hernia or another serious condition.