Hiatus hernia

About hiatus hernia

Your stomach usually sits completely below your diaphragm – the sheet of muscle that separates your chest cavity (where your lungs are) from your abdomen (tummy).
The diaphragm has an opening that the oesophagus (the pipe that goes from your mouth to your stomach) passes through. This opening is called the hiatus. A hiatus hernia occurs when part of your stomach slides through the hiatus into your chest cavity.
Hiatus hernia is very common – three in 10 people over 50 will get it. However, it’s likely that this number may be higher because many people with a hiatus hernia have very mild symptoms or none at all, and may not realise that they have the condition.

This is the most common type, affecting eight out of 10 people with a hiatus hernia. In a sliding hiatus hernia, the junction between the oesophagus and the stomach (known as the gastro-oesophageal sphincter), as well as a portion of the stomach itself, slides up above the diaphragm.

Rolling hiatus hernia

This type (also know as a para-oesophageal hernia) is much less common, affecting only two out of 10 people with a hiatus hernia. Your gastro-oesophageal junction stays in its usual place in the abdomen below the diaphragm, but a portion of your stomach goes through the diaphragm and lies beside the oesophagus.

Symptoms of hiatus hernia

Often, a hiatus hernia won’t cause any symptoms. If you do get any symptoms, they aren’t likely to be serious. The most common is heartburn, which causes a warm or burning sensation in your chest. You’re more likely to have this feeling after meals. Severe heartburn that goes on for a long time is called gastro-oesophageal reflux disease (GORD). This is a common condition where the acidic contents of your stomach flow backwards (reflux) into your oesophagus. This occurs with a sliding hiatus hernia but not a rolling type. It’s possible to have reflux without having a hiatus hernia and vice versa.
Other symptoms of a hiatus hernia include:

• finding it difficult or painful to swallow
• belching
  
• chest pains
• shortness of breath

You might develop a strained, hoarse voice or asthma symptoms from inhaling regurgitated stomach acid, particularly when you’re asleep. Leaning forward, straining or lifting heavy objects can make your symptoms worse, as does being pregnant.

Complications of hiatus hernia

Occasionally, a hiatus hernia can lead to more serious problems. The oesophagus can sometimes become damaged by the acidic contents from your stomach. This happens because a sliding hiatus hernia acts as a trap for any reflux. This allows the acidic fluid to come into contact with your oesophagus.
This damage can sometimes lead to ulcers on the lining of your oesophagus, which may bleed. A bleeding ulcer can sometimes lead to anaemia, a condition where there is not enough haemoglobin (the substance that carries oxygen around your body) in the blood. You’re more likely to develop anaemia if you have a condition that means you have to stay in bed for long periods of time or take non-steroidal anti-inflammatory drugs (NSAIDs). You might vomit blood if you have a bleeding ulcer. If you see blood in your vomit, seek medical attention immediately.
Another complication of reflux caused by a sliding hiatus hernia is scarring and a narrowing (known as a stricture) at the lower end of the oesophagus, which causes food to stick. Acid regurgitation can also lead to Barrett's oesophagus where abnormal cells develop on the inner lining of the lower part of the oesophagus. Barrett’s oesophagus can cause ongoing heartburn, indigestion, vomiting and difficulty swallowing food due to the reflux, although you may not have any symptoms.
A rolling hiatus hernia can sometimes get trapped or pinched by the diaphragm, which means the blood supply to it may be cut off. This is called a strangulated hernia, which can be very painful. If this happens, you will probably need to have an operation immediately to treat it.

Causes of hiatus hernia

The exact reasons why you may develop a hiatus hernia aren’t fully understood at present, but you’re more likely to develop it if you’re over 50, obese or smoke.
Other factors that increase your risk of getting a hiatus hernia include:

• excessive coughing, vomiting, straining or sudden physical exertion
• a weakened diaphragm – this gets weaker as you get older
• if you’ve had a previous operation for a hiatus hernia

Hiatus hernias are more common in women than in men. Women often get reflux symptoms in pregnancy due to the increased pressure in the abdomen as the baby grows.
Conditions such as chronic oesophagitis (inflammation of the lining of the oesophagus) can cause your oesophagus to shorten. This can increase your risk of developing a hiatus hernia.

Diagnosis of hiatus hernia

Often, hiatus hernias are discovered during chest X-rays or scans for unrelated symptoms. This is because a hiatus hernia often doesn't cause any symptoms.
If your GP thinks you might have a hiatus hernia, he or she will ask you about your symptoms. You probably won’t need to be examined as this doesn’t usually help with diagnosis of a hiatus hernia. Your GP may refer you to a gastroenterologist (a doctor who specialises in identifying and treating conditions that affect the digestive system) for tests, which may include the following.

• Upper gastrointestinal (GI) series. This uses X-rays to help diagnose problems of the upper GI tract, which includes the oesophagus, stomach and duodenum (the first part of the small bowel). This is the most common examination to diagnose a hiatus hernia. Upper GI series involves swallowing a drink containing a substance called barium. The barium liquid coats the lining of the upper GI tract and shows up any problems more clearly.
• Endoscopy (also known as gastroscopy). This is a test that allows a doctor to look at the inside of the body. The test is done using a narrow, flexible, tube-like telescopic camera called an endoscope. The endoscope is passed through your mouth and your doctor uses it to see your upper GI tract. He or she can also use this test to take a biopsy (a tissue sample) if needed.
• Manometry and pH testing. Your doctor might arrange for you to have manometry and pH testing if he or she is unsure if your symptoms are due to reflux. This procedure involves swallowing a very fine probe, which measures the pressure and acidity at different levels in the oesophagus.

You might have a CT scan or MRI scan if your doctor still isn’t sure whether or not you have a hiatus hernia, but these tests aren’t usually used to diagnose a hiatus hernia.

Treatment of hiatus hernia

Treatment for a hiatus hernia is usually aimed at relieving and reducing your symptoms. Sometimes your GP or gastroenterologist will prescribe you medicine. You might have to have an operation, but this is rare.

Self-help

You can reduce your symptoms of a hiatus hernia and prevent further problems by making the following lifestyle changes.

• If you’re overweight or obese, lose excess weight.
• Eat smaller, more frequent meals and try not to eat just before you go to bed.
• Try not to smoke or drink alcohol.
• Wear comfortable clothes that aren’t tight-fitting.
• Raise the head of your bed before sleeping in it.
• Try not to have too many drinks that are acidic or contain caffeine, such as orange juice, sugary, fizzy drinks, coffee or energy drinks.
• There are certain foods you should try not to eat, such as onions and chocolate, or foods that are spicy or fatty.

Medicines

There are a variety of medicines available that can help reduce symptoms of a hiatus hernia. The most common are antacids, which work by neutralising the acid in your stomach. The effectiveness of antacids varies from person to person. If you find they don’t relieve your symptoms, your GP may recommend a different medicine. See our Common questions for more information.

Surgery

You won’t usually need to have surgery if you have a sliding hiatus hernia unless your symptoms are very severe. You’re more likely to have surgery if you have a rolling hiatus hernia. This is to prevent it from becoming strangulated or to stop complications developing, such as bleeding or a blockage of the oesophagus.
Surgery is usually done as a keyhole procedure through a small incision in your chest or abdomen using a laparoscope (a narrow, flexible, tube-like telescopic camera). This allows your surgeon to see inside your body into your abdomen. Surgical instruments can then be inserted through further small incisions.
During the procedure, the hiatus hernia is corrected by bringing your stomach down into your abdomen. The upper part of your stomach is then wrapped around the lower part of your oesophagus to make your gastro-oesophageal sphincter stronger. This type of surgery is called Nissen’s fundoplication. If your diaphragm has a big hole, your surgeon may use a type of mesh to repair it.
You will probably need to stay in hospital for up to three days after your operation. You can usually return to work within two to three weeks if you have keyhole surgery.

Sometimes, you may need to have open surgery to repair a hiatus hernia. This is done through a cut in your abdomen. The recovery period is usually longer if you have open surgery.

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