Hiatal hernia is the protrusion of a portion of the stomach into the chest cavity through a natural opening in the diaphragm (between the abdomen and the chest cavity).

This condition can interfere with a sphincter (muscle) that prevents the backflow (reflux) of stomach acid into the esophagus. People with hiatal hernias may also have gastroesophageal reflux disease (GERD), a condition marked by the reflux of acid into the esophagus. Hiatal hernias are common, and are associated with increasing age (especially in people over 50) and increasing weight. In addition, women are more prone to hiatal hernias than men.

There are several different types of hiatal hernias including sliding hiatal hernia, paraesophageal hiatal hernia and diaphragmatic hernia (due to birth defect or trauma).  

It is unclear why most hiatal hernias develop. The association of age and weight may be related to the gradual slippage of the stomach into the chest and the cumulative effect of increased pressure within the abdomen over time.

Most hiatal hernias do not cause symptoms. However, people with hiatal hernias and GERD may experience heartburn, difficulty swallowing and chest pain.

Hiatal hernias may be diagnosed by a physician with a physical examination that follows a medical history. The symptoms may lead a physician to perform a barium x-ray and/or endoscopy to confirm the presence of a hiatal hernia.

Treatment for GERD and hiatal hernias varies but may include lifestyle changes (e.g., losing weight) or medications (e.g., antacids, H2 blockers and proton-pump inhibitors). In severe cases, surgery to strengthen the sphincter and/or pull the stomach back into the abdomen may be performed. These procedures may include thoracotomy, laparotomy or laparoscopic surgery.

Hiatal hernias cannot usually be prevented, but there are ways to prevent the gastroesophageal reflux that often accompanies them, such as avoiding foods and drinks that aggravate reflux, elevating the head of the bed and quitting smoking.

Hiatal hernia is a condition that occurs when a portion of the stomach protrudes into the chest cavity through an opening in the diaphragm.

The diaphragm is a dome-shaped muscle used for breathing that separates the chest cavity and the abdomen. The esophagus passes through an opening in the diaphragm (called a hiatus) into the stomach. Under normal circumstances, most of the esophagus is located above the diaphragm and the stomach is located below the diaphragm. In patients with hiatal hernias, the muscle tissue around the hiatus becomes weak, causing the upper part of the stomach to bulge through the diaphragm into the chest cavity.

Hiatal hernias may also interfere with the functioning of the esophagus and stomach. Normally, the diaphragm is aligned with the lower esophageal sphincter (LES), a muscle that serves as a valve between the esophagus and stomach. When food passes through the esophagus, the LES relaxes and allows it to enter the stomach. After the food passes, the LES constricts and prevents stomach acid from flowing back into the esophagus.

Ordinarily, the diaphragm supports and puts pressure on the LES. In patients with hiatal hernias, however, the LES is located above the diaphragm. This reduces the pressure of the LES, and allows stomach acid to flow back into the esophagus.

In some patients, a hiatal hernia can cause a large part of the stomach to protrude through the diaphragm, which can exert pressure on the lungs and diaphragm. Patients with larger hiatal hernias can easily develop ulcers within the hiatal hernia (Cameron’s erosions) and especially with the use of nonsteroidal anti-inflammatory drugs (NSAIDs).

If the portion of the stomach that protrudes into the chest cavity becomes twisted, this can result in pain, vomiting and possible obstruction of the esophagus. In rare cases, the entire stomach protrudes into the chest cavity and may result in restriction of blood flow to the stomach. This is a serious condition that requires immediate surgery.

Because hiatal hernias can interfere with the functioning of the diaphragm and LES, patients have a greater of risk of developing certain conditions, including:

• Gastroesophageal reflux disease (GERD). A condition marked by the backflow (reflux) of stomach acid into the esophagus. The main symptom is heartburn.
  

  

• Erosive esophagitis. Inflammation or irritation of the esophagus, usually caused by acid reflux and often resulting in heartburn and painful swallowing.

If not treated properly, recurrent cases of GERD can lead to complications, including:

• Difficulty swallowing (dysphagia). Stomach acid can cause inflammation and scarring in the esophagus. This narrows the esophagus and makes it hard to swallow.
  
  
• Barrett's esophagus. A small number of people with chronic GERD develop Barrett’s esophagus, a precancerous condition in which the cells lining the lower part of the esophagus are changed or replaced with abnormal cells. Patients with Barrett’s esophagus are at a higher risk of developing esophageal cancer.
  
  
• Esophageal cancer. Most patients with Barrett’s esophagus do not develop cancer. However, some develop adenocarcinoma. The main symptom of an esophageal tumor is progressing difficulty with swallowing.

Hiatal hernias are common in the United States and are associated with advancing age (especially in people age 50). Women and people who are overweight are also more likely to develop hiatal hernias.

There are several different types of hiatal hernias. They include:

• Sliding hiatal hernia. The most common type of hiatal hernia. A portion of the stomach, along with the gastroesophageal junction (place where the stomach is connected to the esophagus), protrudes above the diaphragm.
  
  
• Paraesophageal hiatal hernia. A portion of the stomach protrudes above the diaphragm, but lies beside the esophagus. The gastroesophageal junction is located in its normal place.
  
  
• Mixed diaphragmatic hernia. Hiatal hernias that include aspects of both sliding and paraesophageal hiatal hernias.
  
  
• Post-traumatic diaphragmatic hernia. Hiatal hernias that occur due to blunt trauma (such as a motor vehicle accident) or penetrating trauma (such as a gunshot wound).
  
  
• Diaphragmatic hernia. Some hiatal hernias are present at birth, although this is rare.

The cause of hiatal hernia is not known, but there are several factors that increase the risk of developing a hiatal hernia. They include:

• Age. The membranes that connect the gastroesophageal junction (place where the stomach is connected to the esophagus) and the diaphragm weaken over time. This increases the risk of developing a hiatal hernia.
  
  
• Gender. Hiatal hernias are more common in women than in men. This may be due to pregnancy, which exerts pressure on the abdomen.
  
  
• Weight. Hiatal hernias are more common in people who are overweight or obese. In some instances, hiatal hernias develop in patients who undergo bariatric surgery to lose weight.
  
  
• Certain activities. Activities such as persistent or severe coughing, vomiting and heavy lifting exert pressure on the abdomen and increase the risk of developing hiatal hernias.

Most hiatal hernias do not cause symptoms. However, people with hiatal hernias that result in reflux (the flow of stomach acid back into the esophagus) may experience the following:

• Heartburn
• Difficulty swallowing (dysphagia)
• Chest pain
• Vomiting

In most cases, symptoms are mild and pass quickly. A physician should be contacted if symptoms are severe or persistent.

In rare cases, a paraesophageal hiatal hernia (in which a portion of the stomach protrudes above the diaphragm, but lies beside the esophagus) may get trapped by the diaphragm and lose blood supply. If this occurs, it results in a serious and painful condition called strangulation. A physician should be contacted if this condition is suspected because it requires immediate surgery.

Hiatal hernias are closely associated with symptoms related to gastroesophageal reflux disease (e.g., heartburn, chest pain). GERD often occurs along with a hiatal hernia. A physician will obtain a medical history and perform a physical examination for GERD.

A physician may try to rule out more serious conditions that may be causing the symptoms. For example, patients experiencing chest pain could have heart disease, which require additional tests before it can be eliminated as a possible cause. Patients may also be referred to a physician who specializes in diseases and conditions of the gastrointestinal tract (gastroenterologist).

Some tests that may be performed include:

• Barium x-ray (upper GI series). Test that involves ingesting liquid barium and performing x-rays. Barium x-rays provide images of the esophagus, stomach and upper part of the small intestine and can help determine whether a hiatal hernia is present.
  
  
• Endoscopy. This is one of the most common tests used to evaluate the esophagus. A small tube with a light and camera (endoscope) is inserted into the esophagus, stomach and small intestine. It can help determine whether there is acid reflux or a hiatal hernia.

Treatment for hiatal hernia varies depending on the severity and symptoms experienced. Patients experiencing no symptoms typically do not require treatment for hiatal hernias.

Patients who develop gastroesophageal reflux disease (GERD) or other conditions caused by a hiatal hernia may be treated in a variety of ways. They include:

• Lifestyle changes. Minimizing activities, such as heavy lifting, that put pressure on the abdomen can ease symptoms. Modifying diet and losing weight can also help.
  
  
• Medications. If lifestyle changes are not effective, medications may ease symptoms. They include:
  
  
• • Antacids. They are available over-the-counter and work by neutralizing stomach acid. Antacids, however, do not heal damage to the esophagus caused by stomach acid.
    
    
  • H2 blockers. Medications that reduce the acid levels in the stomach by blocking the chemical used to make acid. They are available over-the-counter and by prescription.
    
    
  • Proton pump inhibitors. Medications that reduce the amount of acid in the stomach by inhibiting its production. They are more effective than H2 blockers and can relieve symptoms in almost any patient with GERD.
    
    
• Surgery. If lifestyle changes and medications are not effective, surgery may be performed. This is particularly true if patients are experiencing severe symptoms, such as chronic bleeding or difficulty breathing. The goal of surgery may be to pull the stomach down into the abdomen or to make the hole in the diaphragm smaller. Another method (fundoplication) is performed to reconstruct a weak lower esophageal sphincter (LES) by wrapping the upper part of the stomach around the esophagus. Different types of possible surgeries include:
  
  
• • Thoracotomy. Performed by making a single incision in the chest wall.
    
    
  • Laparotomy. Performed by making a single incision in the abdomen.
    
    
  • Laparoscopic surgery. Performed by making several incisions in the abdomen and inserting an instrument with a fiber-optic camera (laparoscope). During surgery, images can be viewed on a video monitor. This type of surgery usually causes less pain and scarring and involves a shorter hospital stay.
    
    
  • Endoscopic surgery. Newest field of surgery for hiatal hernia and GERD that uses minimal or not external incisions. This type of surgery is time-consuming and it is unclear if it will become widely used.
    
    

Although development of a hiatal hernia cannot be prevented, there are a variety of ways to prevent the gastroesophageal reflux that often accompanies it. They include:

• Eat small meals. Large meals cause the stomach to grow and push it into the chest.
  
  
• Avoid certain medications. Some types of medications worsen reflux, such as calcium channel blockers (to treat high blood pressure), nonsteroidal anti-inflammatory drugs (NSAIDs), sedatives and tranquilizers. Recent research also indicates that taking a certain type of sleeping pills may increase the risk of developing nighttime heartburn. Consult a physician to determine whether another medication can be taken instead.
  
  
• Elevate the head of the bed. Raise the head of the bed 6 to 8 inches (15 to 20 centimeters). Elevating the head and shoulders over the stomach allows gravity to keep acid from refluxing.
  
  
• Do not wear tight-fitting clothes. This can put pressure on the stomach.
  
  
• Promote salivation by chewing gum or using lozenges. This helps clear acid that has entered the esophagus.
  
  
• Practice relaxation techniques. Deep breathing, meditation and yoga can reduce stress and decrease reflux.
  
  
• Lose weight. This can help reduce pressure on the stomach.
  
  
• Stop smoking. Smoking increases reflux and dries saliva. Saliva helps protect the esophagus from stomach acid.
  
  
• Avoid alcohol.

Traditionally, physicians have recommended that patients with GERD avoid certain foods and beverages, including citrus fruits, chocolate, fatty foods, spicy foods, tomato sauce, mint and carbonated and/or caffeinated beverages, which may increase acid production or relax LES muscles. Recent research questions the benefit of such dietary changes.

In addition, physicians typically recommend that patients avoid lying down for at least three hours after eating. The benefit of this has also not been well supported by recent research.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to hiatal hernia:

1. What is a hiatal hernia?
   
   
2. Why do you suspect I may have a hiatal hernia?
   
   
3. What type of hiatal hernia do I have?
   
   
4. If I have a hiatal hernia will I develop gastroesophageal reflux disease (GERD)?
   
   
5. Is it possible that I have a hiatal hernia even though I am not experiencing symptoms?
   
   
6. How are hiatal hernias diagnosed?
   
   
7. Is it necessary to treat my hiatal hernia?
   
   
8. What is the best way to treat my hiatal hernia?
   
   
9. Will my GERD disappear after my hiatal hernia is treated?
   
   
10. Can hiatal hernias be prevented?