What Is a Hiatal Hernia?

A hiatal hernia occurs when abdominal contents slide through a hole in the diaphragm muscle and up into the chest. It usually involves a part of the stomach. In rare cases, some other part of the intestine — or even the spleen or pancreas — can move into the chest.

Hiatal hernias are common, affecting up to 20% of people. The condition is usually harmless, and most people don’t have any symptoms. But there are some scenarios where people need treatment. Here we’ll discuss what causes a hiatal hernia, as well as the symptoms, diagnosis, and treatment of this type of hernia.

Causes of a hiatal hernia

The diaphragm is a muscle that separates the chest cavity from the abdominal cavity. Normally the esophagus is the only part of the digestive tract that travels through the diaphragm. But sometimes organs that belong in the abdomen — like the stomach — can slide up through the hole in the diaphragm. Anything that increases the pressure in the abdomen can cause this, such as:

• Large body size

• Heavy lifting or straining

• Tight-fitting clothing or belts

• Pregnancy

Weakening of the diaphragm muscle can also make someone more likely to develop a hiatal hernia. This can happen due to the following: 

• Condition present at birth

• Prior surgery

• Older age

• Injury to the diaphragm muscle

Symptoms of a hiatal hernia

Most of the time, a hiatal hernia doesn’t cause any symptoms. If there are symptoms, they’re usually due to gastroesophageal reflux disease (GERD), including:

• Burning discomfort in the chest or upper abdomen

• Acidic taste in the mouth

• Cough

• Hoarse voice

• Nausea

When someone has these symptoms, they tend to be worse after eating. Other triggers include certain foods, large meals, or lying down after eating.

In rare cases, the pain can be very severe if the portion of the stomach or intestine that slides through the diaphragm gets stuck or trapped. This cuts off the oxygen supply to that part of the digestive tract, leading to a sudden onset of symptoms like pain or vomiting.

Diagnosis of a hiatal hernia

Since most hiatal hernias don’t cause symptoms, diagnosis often comes from a test that’s done for some other reason, like an X-ray or CT scan of the chest. If the hernia is causing symptoms, a provider may recommend an endoscopy, which can also help with the diagnosis. 

After a diagnosis, your provider may recommend additional testing to get more information about the extent of the hernia. This is especially true if the hernia causes severe symptoms and you’re considering surgery. More extensive testing includes:

• Barium swallow: This test is a special type of X-ray where you first drink a liquid that contains barium. The barium coats and outlines the esophagus and stomach, which can better show the hernia.

• Esophageal manometry: A provider places a probe in the esophagus to see how it contracts during swallowing. Normal esophageal function is important if the hiatal hernia needs surgery. 

• Reflux monitoring: A provider places a probe into the esophagus for a period of time to monitor the pH and check for the presence and severity of GERD. A hernia that causes severe GERD may benefit from surgery.

Hiatal hernia treatment

Most hiatal hernias don’t need treatment unless they cause symptoms. Even if the hernia causes symptoms, the first treatment is usually medications that help with GERD. Acid-blocking medications called proton pump inhibitors (PPIs) can help with the symptoms. Providers usually recommend PPIs for at least 8 weeks. If the medication helps, you’ll usually continue to take them at the lowest dose that controls the symptoms.

To help control any symptoms, experts also recommend lifestyle changes, such as:

• Addressing weight loss if appropriate

• Avoiding trigger foods for GERD symptoms (like spicy or acidic foods)

• Eating smaller, more frequent meals 

• Avoiding tight-fitting clothing

• Waiting at least 1 hour after eating before lying down

• Raising the head of the bed to help avoid reflux while sleeping

If lifestyle changes and medications aren’t enough to control the symptoms, you and your provider may consider surgery to help fix the hernia. A surgeon will also repair a hiatal hernia if someone has weight-loss surgery. This includes procedures like gastric bypass and gastric sleeve. In some cases, healthcare teams may consider surgery earlier if there’s a high risk that the hernia will become entrapped.

Is a hiatal hernia a life-threatening condition?

Most hiatal hernias aren’t dangerous. But if the hernia is at high risk of becoming stuck or entrapped, it may cause hernia incarceration, a serious, life-threatening complication. This is when the oxygen to a portion of the intestine is cut off, which causes that part of the intestine to die. It can happen due to the size or shape of a hiatal hernia.

Hernia incarceration is an emergency that needs immediate treatment. It’s associated with severe and worsening pain, fever, and possible infection. But this is a very rare complication of a hiatal hernia. Your healthcare provider can help you figure out if your hiatal hernia is at high risk of this complication.