Hiatal Hernia: Symptoms, Causes and Treatment

What Is a Hiatal Hernia?

Hello, I am Dr. Emre Gecer. A hiatal hernia — known medically as hiatus hernia — is the displacement of part of the stomach through the natural opening of the diaphragm (the oesophageal hiatus) up into the chest (mediastinum).

The diaphragm is a large, dome-shaped muscle that separates the chest cavity from the abdomen. The oesophagus passes through an opening in the diaphragm called the oesophageal hiatus to connect with the stomach. Under normal conditions, this opening hugs the oesophagus tightly. In a hiatal hernia, the opening loosens or widens and the upper part of the stomach slides upward.

Hiatal hernia is extremely common. In adults over 50, prevalence can reach 60%. The vast majority of cases are asymptomatic and discovered incidentally.

Types of Hiatal Hernia

Type I: Sliding Hernia — 95%

This is the most common type, accounting for about 95% of all hiatal hernias. The gastro-oesophageal junction (GOJ) and the fundus of the stomach slide together upwards through the diaphragmatic hiatus. This type often reduces spontaneously when standing or swallowing.

• Usually asymptomatic
• When symptomatic, GERD (reflux) symptoms predominate
• Impairs the function of the lower oesophageal sphincter (LOS), predisposing to acid reflux

Type II: Paraoesophageal (Rolling) Hernia

The GOJ stays in its normal position while the fundus of the stomach herniates upward through the diaphragmatic hiatus. It is rarer (around 5%) but carries a higher risk of complications.

• Risk of strangulation and volvulus
• Gastric ischaemia and necrosis can develop
• Surgical repair is generally recommended even when asymptomatic (somewhat debated)

Type III: Mixed Hernia

Has both sliding and paraoesophageal components. The GOJ has migrated upwards and the gastric fundus has additionally herniated.

Type IV: Complex Hernia

A large portion of the stomach or other abdominal organs (colon, spleen, small intestine, omentum) herniates through the diaphragmatic hiatus into the chest. This is the rarest and most serious type.

Causes and Risk Factors

A hiatal hernia develops when the structures surrounding the diaphragmatic hiatus (the phreno-oesophageal ligament and the crural musculature) weaken. Contributing factors include:

• Ageing: The single most important risk factor — connective tissue and muscle strength decline with age
• Obesity: Raises intra-abdominal pressure; a linear relationship between BMI and hiatal hernia has been demonstrated
• Chronic cough: Persistent coughing from COPD or asthma raises intra-abdominal pressure
• Chronic constipation and straining: Sustained increases in intra-abdominal pressure
• Heavy lifting: Repeated rises in intra-abdominal pressure
• Pregnancy: The growing uterus and hormonal changes
• Smoking: Contributes to connective-tissue weakening
• Genetic predisposition: Some people have a congenitally wide hiatus
• Trauma or surgery: Disruption of diaphragmatic anatomy

Symptoms

Most hiatal hernias are asymptomatic and discovered incidentally (during a barium swallow, upper GI endoscopy or CT scan). When symptomatic, the following may be seen:

GERD-Related Symptoms (Common in Type I)

• Heartburn: A burning sensation behind the sternum, worse after meals and when lying down
• Regurgitation: Acid or food rising back up into the mouth
• Dysphagia: Difficulty swallowing (particularly with solid food)
• Chronic cough and hoarseness: Due to laryngopharyngeal reflux
• Belching and bloating

Paraoesophageal Hernia Symptoms (Types II–IV)

• Epigastric or chest pain: More pronounced after meals
• Early satiety: Due to pressure from the herniated stomach segment
• Shortness of breath: Pressure on the lungs in large hernias
• Dysphagia: From mechanical obstruction
• Iron-deficiency anaemia: Chronic, occult bleeding from Cameron ulcers

Complications

Gastric Volvulus

Rotation of the stomach around its own axis within a paraoesophageal hernia. This is an acute surgical emergency. It presents with Borchardt's triad: severe epigastric pain, persistent retching without vomiting and inability to pass a nasogastric tube.

Strangulation and Ischaemia

Compromise of the blood supply to the herniated stomach can lead to ischaemia and necrosis, requiring urgent surgical intervention.

Cameron Ulcers

Linear ulcers that form where the diaphragmatic crus rubs against the gastric mucosa in large hiatal hernias. They can cause chronic occult bleeding and iron-deficiency anaemia.

Barrett's Oesophagus

Replacement of the squamous epithelium at the lower end of the oesophagus by intestinal metaplasia, in the context of chronic GERD. It is a precancerous condition for oesophageal adenocarcinoma.

Diagnostic Methods

Upper GI Endoscopy (Gastroscopy)

The most frequently used investigation for direct visualisation of the hernia, grading of oesophagitis and screening for Barrett's oesophagus. If the distance between the diaphragmatic impression and the GOJ exceeds 2 cm, a hiatal hernia is diagnosed.

Barium Swallow (Oesophago-Gastric Series)

An X-ray series taken after the patient drinks a barium contrast medium. It provides detailed information on the type, size and position of the hernia, and is particularly superior to endoscopy for anatomical assessment of paraoesophageal hernias.

Oesophageal Manometry

Measures LOS pressure and oesophageal motility. Important in pre-operative work-up — if oesophageal dysmotility is present, the choice of surgical technique may need to be adjusted.

pH Monitoring / Impedance

Objective measurement of acid reflux over 24 hours. Used to confirm GERD and to evaluate response to PPI therapy.

Computed Tomography (CT)

Helpful for assessing anatomical detail in large paraoesophageal hernias and for surgical planning.

Treatment

1. Lifestyle Modifications

For asymptomatic or mildly symptomatic sliding hernias, lifestyle changes are the first-line approach:

• Weight loss: The most effective way to reduce intra-abdominal pressure; even a 5–10% loss can significantly ease symptoms
• Elevate the head of the bed: Raise it by 15–20 cm (by placing blocks under the bedposts rather than stacking pillows) to reduce nocturnal reflux
• Meal timing: Eat your last meal at least 3 hours before going to bed
• Portion control: Smaller, more frequent meals; large portions increase gastric distension
• Avoid triggers: Fatty meals, chocolate, peppermint, caffeine, alcohol, fizzy and acidic drinks, spicy food
• Avoid tight clothing: Belts and garments that compress the abdomen
• Stop smoking: Smoking lowers LOS pressure and worsens reflux

2. Medical Therapy

Medical therapy is used to control GERD symptoms:

• Proton-pump inhibitors (PPIs): Omeprazole, lansoprazole, pantoprazole, esomeprazole — strongly suppress gastric acid production; the first-line option in GERD
• H2-receptor antagonists: Famotidine — weaker acid suppression than PPIs; used for mild cases or as an add-on for nocturnal reflux
• Antacids: Aluminium/magnesium hydroxide — fast but transient symptom relief
• Alginate-based products: Form a floating barrier on top of the gastric contents, mechanically reducing reflux (Gaviscon and similar)

3. Surgical Treatment

Surgery is indicated in the following situations:

• Persistent symptoms despite maximum-dose PPI therapy
• Younger patients who do not wish to take PPIs long term
• Patients who cannot tolerate PPIs due to side effects
• Large paraoesophageal hernias (Types II–IV) — risk of strangulation and volvulus
• Symptomatic Cameron ulcers
• Reflux-related laryngospasm or aspiration pneumonia

Nissen Fundoplication

The most common anti-reflux operation. The fundus of the stomach is wrapped 360 degrees around the lower oesophagus. This wrap increases LOS pressure and mechanically prevents reflux.

• Usually performed laparoscopically (keyhole surgery)
• Success rate: 85–90% (long-term symptom control at 10 years)
• Possible side effects: transient dysphagia, gas-bloat syndrome (difficulty belching)

Other Surgical Options

• Toupet fundoplication: A 270-degree partial wrap; preferred in patients with weak oesophageal motility
• LINX device: A ring of magnetic beads placed around the LOS; it opens during swallowing and stays closed at rest to prevent reflux (a relatively new option)

When Should You See a Doctor?

• Reflux symptoms more than twice a week
• Symptoms persisting despite PPI therapy
• Difficult or painful swallowing
• Unintentional weight loss
• "Coffee-ground" vomit or visible blood in vomit
• Black, tar-coloured stool (melaena)
• Sudden, severe chest or abdominal pain (possible strangulation or volvulus — seek emergency care)
• Unexplained iron-deficiency anaemia

Conclusion

Hiatal hernia is extremely common in the general population and is usually asymptomatic. Sliding hernias are generally managed successfully with lifestyle modifications and PPI therapy. Paraoesophageal hernias, because of the risks of strangulation and volvulus, require closer monitoring and, when necessary, surgical repair. If you have long-standing or treatment-resistant reflux symptoms, I recommend seeing a gastroenterologist or general surgeon.

Wishing you good health.
Dr. Emre Gecer

References

• Sabiston Textbook of Surgery, 21st Edition — Chapter: Hiatal Hernia and Gastroesophageal Reflux
• Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11th Edition
• Harrison's Principles of Internal Medicine, 22nd Edition
• Kohn GP, et al. SAGES Guidelines for the management of hiatal hernia. Surg Endosc. 2013