If you suffer from chronic heartburn or sometimes have trouble swallowing, a hiatal hernia may be the culprit. This condition occurs when the upper part of your stomach bulges through an opening in your diaphragm.
Hiatal hernia symptoms can be mild or severe, depending how big the opening is.
At UPMC, our providers often treat smaller hiatus hernias with medication. If your hiatal hernia is large, surgery may be an option.
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What Is a Hiatal Hernia?
A hiatal hernia is a common condition in which the top of the stomach pushes through an opening in the diaphragm.
Your diaphragm is the thin muscle that separates your chest from your belly. It has a small opening called the hiatus. The esophagus — the funnel-shaped tube that moves food into the stomach — passes through the hiatus before it connects to the stomach.
When the hiatus gets stretched out over time, the stomach can bulge up through the opening. Stomach acid can come up through the esophagus and cause symptoms of gastroesophageal reflux disease (GERD).
Most of the time, hiatal hernia is not serious. Many people don’t even know they have the condition. But if the hiatal hernia is large, it can cause more serious problems.
What are the types of hiatal hernia?
There are four types of hiatal hernias, broken down into two categories — sliding hiatal hernias and paraoesophageal hiatal hernias. The paraoesophageal (beside the esophagus) hiatal hernias are much less common.
Sliding hiatal hernia
- Type 1 — This is the most common type, making up more than 95% of all hiatal hernias. It happens when the part of the esophagus connected to the stomach slides up through the hiatus and slides back down.
Paraoesophageal hiatal hernias
- Type 2 — The upper part of the stomach pushes into the hiatus next to the esophagus. Some providers call it a rolling hiatal hernia.
- Type 3 — This is a paraoesophageal hiatal hernia combined with a sliding hiatal hernia. The part of the esophagus that connects to the stomach slides up through the hiatus. At the same time, another part of the stomach pushes through the hiatus next to the esophagus.
- Type 4 — This type is the rarest and most serious of hiatal hernias and can only occur if the hiatus is very wide. Both the stomach and another organ push up through the opening. The other organ may be the small intestine, the colon, or the spleen.
How common is hiatal hernia?
Hiatal hernia is a common condition, especially when you get older. In the U.S., about 55% to 60% of people over age 50 have hiatal hernias. It is more common in women than in men.
In most cases, hiatal hernia is not a serious problem. You may not even know you have one. In fact, only about 9% of people who have a hiatal hernia have any symptoms.
What causes hiatal hernia?
Providers usually don’t know what causes a hiatal hernia. It may happen because of muscle weakness, age, or injury.
Hiatal hernia risk factors
Although providers don’t know specific causes for hiatal hernia, they do know some people are more prone to them. If you have frequent pressure on your abdomen for any reason, you are more likely to develop a hiatal hernia.
You’re at higher risk for hiatal hernia if you:
- Are obese.
- Are over 50 years of age.
- Are pregnant.
- Have a birth defect.
- Have a chronic cough.
- Have a family history of hiatal hernia.
- Have chronic constipation.
- Have chronic obstructive pulmonary disease (COPD).
- Have had previous surgeries.
- Smoke tobacco.
Complications of hiatal hernia
The most common complication of hiatal hernia is gastroesophageal reflux (GERD). GERD happens when stomach acid flows into the esophagus. Untreated, GERD can eventually cause damage to your esophagus.
Symptoms of GERD include:
- Bad breath
- Breathing problems
- Chronic inflammation
- Dry cough
- Heartburn
- Nausea
- Pain
- Problems swallowing
- Tooth damage
- Ulcers
- Vomiting
Another complication of hiatal hernia is rare, but serious. A strangulated hiatal hernia can occur when the stomach or other organs get stuck and compressed in the hiatus.
Strangulated hiatal hernia is a medical emergency that could lead to serious complications, such as:
- Bleeding.
- Blockage of the digestive tract.
- Breathing difficulties.
- Inflammation.
- Pain.
- Perforation of an organ.
- Stomach ulcers.
- Tissue death.
How can I reduce my risks of hiatal hernia?
There’s no certain way to make sure you don’t get a hiatal hernia. But you may be able to reduce your hiatal hernia symptoms with some healthy lifestyle habits.
- Avoid foods that trigger acid reflux —These may vary from person to person. They often include caffeine, alcohol, spicy foods, citrus, chocolate, tomato sauce, and fried or fatty foods.
- Avoid straining from lifting heavy objects.
- Don’t eat huge meals, especially late at night.
- Eat slowly and chew food thoroughly.
- Manage constipation — Straining on the toilet can aggravate a hiatal hernia. Get enough fiber, drink lots of water, and exercise several times a week to keep your bowel movements regular.
- Quit smoking.
- Treat chronic coughing.
What Are the Signs and Symptoms of Hiatal Hernia?
A small hiatal hernia may not cause any symptoms. You may not notice it for years. Typically, a hiatal hernia gets bigger as you get older.
Common hiatal hernia symptoms typically overlap with signs of GERD. They include:
- Acid reflux
- Belly pain
- Burping
- Difficulty swallowing
- Dry cough
- Feeling full
- Heartburn
- Chest pain
When should I see a doctor about my hiatal hernia symptoms?
If your hiatal hernia symptoms are affecting your quality of life or interfering with your daily activities, you should see a medical provider. Your primary care provider (PCP) may refer you to a gastroenterologist or general surgeon.
How Do You Diagnose Hiatal Hernia?
If you don’t have symptoms of hiatal hernia, you may feel surprised to you find out you have one.
A hiatal hernia often shows up on a test for another problem such as:
- Abdominal pain
- Chest pain
- GERD
- Heartburn
Tests to diagnose hiatal hernia
If you have symptoms of a hiatal hernia, your provider may use one or more of the following tests to diagnose it:
- Barium swallow — An imaging test where you ingest barium. A provider takes x-rays to look at your esophagus and upper gastrointestinal (GI) tract. The barium lets providers have a clearer look at your internal organs.
- Chest x-ray — Radiation takes photos of your chest cavity, where your esophagus is.
- Endoscopy — A test where a provider puts an endoscope (a long, thin tube) down your throat. You will have medicine that makes you sleep or get very sleepy. A camera on the endoscope shows providers your esophagus and stomach.
- Esophageal manometry (pressure study) — Providers thread a thin tube through your nose and into your esophagus. It measures the pressure when you swallow.
- Esophageal pH test — Providers place a tiny capsule in your esophagus. It measures how frequently stomach acid flows into the esophagus. It stays in place between 24 and 96 hours.
How Do You Treat Hiatal Hernia?
If your hiatal hernia doesn’t bother you, you won’t need treatment. Your provider may recommend the “wait and watch” method. They will keep an eye on it to see if it gets bigger or starts causing problems.
However, if you already have symptoms of GERD or another problem caused by your hiatal hernia, treatment can help. A hiatal hernia will not go away on its own.
The goal of hiatal hernia treatment is to ease the discomfort of symptoms and prevent complications. Some simple lifestyle habits may be enough. In more severe cases, you may need surgery to return the stomach to its original position in the abdominal cavity.
Lifestyle changes for hiatal hernia
If your hiatal hernia is not severe, you can make some simple changes at home to manage symptoms.
Some changes you can make to lessen symptoms include:
- Cut out fatty foods — Rich meals and fried food can trigger more stomach acid, which can aggravate your hiatal hernia.
- Don’t eat late at night — Lying down with a belly full of food allows stomach acid to pass more easily into the esophagus.
- Eat smaller, more frequent meals — Eating a large meal that fills your stomach can put pressure on the hiatal hernia.
- Elevate the head of your bed — Keeping your upper body elevated takes advantage of gravity and can keep GERD symptoms at bay.
- Maintain a healthy weight — Being overweight can add to the pressure on your stomach and increase the size of your hiatal hernia.
- Quit smoking — Both smoking and the chronic coughing it can bring can make the muscles around your hiatal hernia weaker.
Medicine for hiatal hernia
If you have occasional bothersome symptoms from your hiatal hernia, over-the-counter (OTC) or prescription medicine may help. These products won’t heal the hiatal hernia or stop acid reflux. Instead, they help ease symptoms by reducing or neutralizing stomach acid.
It’s important not to take these medications for extended periods of time. Your provider can advise you on how to use them.
Your provider may recommend:
- Antacids (Tums, Rolaids).
- H2 receptor blockers (Pepcid).
- Proton pump inhibitors (Prilosec, Nexium).
Surgery for hiatal hernia
In some cases, your provider may recommend surgery to repair your hiatal hernia.
That’s usually the case when:
- Lifestyle changes haven’t helped your hiatal hernia or GERD symptoms.
- Medications are causing side effects.
- Medications aren’t providing enough relief.
- Your hiatal hernia has gotten bigger and you’re at risk for future complications.
- You want to stop taking long-term GERD medicines to manage your symptoms.
The most common surgery to repair hiatal hernia is fundoplication. During the surgery, a surgeon sews the top of your stomach around the end of your esophagus. Doing so adds pressure to the lower esophageal sphincter and helps prevent reflux.
At UPMC, we perform this surgery two different ways. Whenever possible, we use the most minimally invasive procedure.
Laparoscopic surgery
Hiatal hernia surgery can be a minimally invasive laparoscopic procedure. During this type of surgery, surgeons make five or six small (5- to 10-millimeter) incisions in the belly.
A surgeon inserts the laparoscope and surgical instruments through these incisions. The surgeon follows the laparoscope, which transmits a picture of the internal organs to a monitor.
The advantages of minimally invasive surgery include:
- Faster recovery time.
- Less pain and scarring.
- Less risk of infection.
- Smaller incisions.
Open surgery
While we usually perform minimally invasive surgeries at UPMC, there are some reasons you may need open surgery. This traditional operation involves a large incision in the chest wall and a longer recovery period.
Your surgeon may choose open surgery if:
- It's an emergency — If the hernia has cut off your blood supply or you’re having trouble breathing, an immediate open surgery may be necessary.
- You have a large or complex hernia — Open surgery allows surgeons to see the problem better.
- You have scar tissue from previous surgeries.
Is hiatal hernia surgery right for me?
If your hiatal hernia doesn’t bother you, you don’t need treatment. And if you only have symptoms now and again, your provider may recommend watchful waiting. For many people, simple lifestyle changes or medication are enough to improve their symptoms.
If hiatal hernia symptoms affect your quality of life, or prevent you from enjoying daily activities, you should talk to your provider. Hiatal hernia surgery is very successful and can make a big difference in your life.
For people who have obesity, doctors sometimes combine hiatal hernia surgery with weight-loss surgery.
How long does it take to recover after hiatal hernia surgery?
You may need to stay in the hospital for a day or two after your surgery.
At home, you’ll need to take it easy for two to six weeks. Recovery from laparoscopic surgery is usually shorter than recovery from open surgery.
You will need to eat a specific diet for a while. It will begin with clear liquids for a week or so. Then you’ll progress to soft foods, and eventually a normal diet.
