Hiatal hernia
Hernia - hiatal
Hiatal hernia is a condition in which part of the stomach extends through an opening of the diaphragm into the chest. The diaphragm is the sheet of muscle that divides the chest from the abdomen.
This X-ray shows the upper portion of the stomach protruding through the diaphragm (hiatal hernia).
A hiatal hernia occurs when part of the stomach protrudes up into the chest through the sheet of muscle called the diaphragm. This may result from a weakening of the surrounding tissues and may be aggravated by obesity and/or smoking.
The esophagus runs through the diaphragm to the stomach. It functions to carry food from the mouth to the stomach. The esophagus passes through the diaphragm just before it meets the stomach, through an opening called the esophageal hiatus.
Causes
The exact cause of hiatal hernia is not known. The condition may be due to weakness of the supporting tissue. Your risk for the problem goes up with age, obesity, and smoking. Hiatal hernias are very common. The problem occurs often in people over 50 years of age.
This condition may be linked to reflux (backflow) of gastric acid from the stomach into the esophagus.
Children with this condition are most often born with it (congenital). In infants, it often occurs with gastroesophageal reflux.
Symptoms
Symptoms may include:
- Chest pain
- Heartburn, worse when bending over or lying down
- Swallowing difficulty
A hiatal hernia by itself rarely causes symptoms. Pain and discomfort are due to the upward flow of stomach acid, air, or bile.
Exams and Tests
Tests that may be used include:
- Barium swallow x-ray
- Esophagogastroduodenoscopy (EGD)
Treatment
The goals of treatment are to relieve symptoms and prevent complications. Treatments may include:
- Medicines to control stomach acid
- Surgery to repair the hiatal hernia and prevent reflux
Other measures to reduce symptoms include:
- Avoiding large or heavy meals
- Not lying down or bending over right after a meal
- Reducing weight and not smoking
- Raising the head of the bed 4 to 6 inches (10 to 15 centimeters)
If medicines and lifestyle measures do not help control symptoms, you may need surgery.
You've just finished eating a double chili dog, when it hits. That burning, belching feeling, like your dinner has taken a detour back up your throat. You've got heartburn, also known as gastroesophageal reflux disease or GERD, for short. When heartburn becomes a frequent, unwelcome visitor and you're tired of taking medicine to treat it, your doctor may recommend surgery. Normally when you eat, food passes down this tube, called the esophagus. It crosses your diaphragm and enters your stomach through a hole. Sometimes the muscles where your esophagus and stomach meet don't close tightly enough, and this weakness allows acids from your stomach to back up into your esophagus, causing heartburn. The hole in your diaphragm may also be too big, letting part of your stomach slip into an opening in your chest. That's called a hiatal hernia, and it can make your heartburn symptoms even worse. If you don't want to take heartburn medicine anymore, or if you're dealing with complications like ulcers or bleeding in your esophagus, your doctor may recommend surgery to fix your hiatal hernia. Usually the surgery you'll have is called fundoplication. Fundoplication is done while you're under general anesthesia, which means that you'll be asleep and you won't feel any pain. Before your surgery, your doctor will ask you to stop taking drugs like aspirin or warfarin, which makes it harder for your blood to clot. Also, you shouldn't eat or drink anything after midnight the night before your surgery. If you have open surgery, the surgeon will make one large cut in your belly area. With laparoscopic surgery, there are more cuts, but they're much smaller. The surgeon will use a thin tube with a camera attached to see through these tiny holes and perform the surgery. A newer form of the procedure passes a special camera down your mouth into your esophagus. Whatever way the surgery is done, the goal is to close your hiatal hernia with stitches and tighten the opening in your diaphragm to keep your stomach from poking through. The surgeon will also wrap the upper part of your stomach around the end of your esophagus so that acids from your stomach can't back up into your esophagus. Just like any procedure, hiatal hernia surgery can have risks. You might have bleeding, an infection, breathing problems, bloating, or pain when you swallow. Call your doctor for any symptoms that bother you or don't go away. Expect to stay in the hospital for about 4 to 6 days, and then spend a month to 6 weeks recovering at home with the open surgical procedure. Laparoscopic surgery will shorten your hospital stay to 1 to 3 days, and you'll be back on your feet and at work in just 2 to 3 weeks. Anti-reflux surgery is safe, and it works. After your surgery, you should have fewer problems with heartburn. But if that burning feeling creeps back up again, you might need to have a repeat surgery. To avoid another procedure, take your heartburn medicine if you need it. Oh, and take it easy on those chili dogs!
Outlook (Prognosis)
Treatment can relieve most symptoms of hiatal hernia.
Possible Complications
Complications may include:
- Pulmonary (lung) aspiration
- Slow bleeding and iron deficiency anemia (due to a large hernia)
- Strangulation (closing off) of the hernia (very uncommon)
When to Contact a Medical Professional
Contact your health care provider if:
- You have symptoms of a hiatal hernia.
- You have a hiatal hernia and your symptoms get worse or do not improve with treatment.
- You develop new symptoms.
Prevention
Controlling risk factors such as obesity may help prevent hiatal hernia.
References
Battafarano RJ. Esophagus: Management of paraesophageal hernia repair. In: Cameron J, ed. Current Surgical Therapy. 14th ed. Philadelphia, PA: Elsevier; 2023:3-80.
Falk GW, Katzka DA. Diseases of the esophagus. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 129.
Lord KA, Lippincott J. Hiatal hernia. In: Ferri FF, ed. Ferri's Clinical Advisor 2023. Philadelphia, PA: Elsevier; 2023:749.e2-749.e5.
Yates RB, Oelschlager BK. Gastroesophageal reflux disease and hiatal hernia. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 21st ed. St Louis, MO: Elsevier; 2022:chap 43.
Version Info
Last reviewed on: 5/2/2023
Reviewed by: Michael M. Phillips, MD, Emeritus Professor of Medicine, The George Washington University School of Medicine, Washington, DC. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
