Hiatus hernia

Your gullet (oesophagus) connects to your stomach by passing through a gap in your diaphragm called the hiatus. Your diaphragm is a large muscle separating your lungs and your abdomen and helps you breathe. A hiatus hernia develops when part of your intestines, usually the upper part of your stomach, bulges through the hiatus.

A hiatus hernia can affect the diaphragm’s ability to stop stomach acid from escaping into your gullet, triggering acid reflux. This can cause heartburn and, in some cases, gastro-oesophageal reflux disease (GORD).

Having a hiatus hernia is very common and can affect anyone at any age, although it’s more likely if you’re older. It’s estimated that one in three people over the age of 50 have a hiatus hernia. You’re also more likely to develop a hiatus hernia if you’re overweight or pregnant. 

In most cases, a hiatus hernia doesn’t need treatment if it isn’t causing you problems — simple lifestyle changes can relieve any symptoms. However, sometimes hiatus hernia medication or surgery may be necessary. Acid-suppressing medication is usually effective.

Your gastrointestinal tract (gut) is a tube that runs from your mouth to your back passage (anus). Your upper gut includes your gullet, stomach and the first part of your small intestine (duodenum).

Food passes down your gullet and into your stomach through a ring of muscle called a sphincter — the sphincter relaxes to allow food to enter the stomach and closes to stop food and stomach acid from passing backwards into your gullet (reflux). In your stomach, food mixes with acid, which helps digestion. Food then passes into your duodenum.

Your gullet passes through a hole in your diaphragm called the hiatus before it reaches your stomach — your diaphragm is a large muscle that separates your lungs from your abdomen. Muscle fibres in your diaphragm help keep the sphincter at the bottom of your gullet closed to stop acid reflux. Normally, your stomach lies below your diaphragm.

You can manage symptoms of a hiatus hernia, specifically heartburn and acid indigestion, by making changes to your diet. Try to avoid highly acidic foods, as these can weaken the sphincter between your gullet and stomach — this makes it easier for acid to pass back up into your gullet, causing heartburn.

Highly acidic foods include: 

• Certain drinks ie alcohol, coffee, cranberry juice, fizzy drinks and tea
• Chocolate
• Citrus fruit and their juices eg grapefruit, lemons, oranges and tomatoes
• Dairy products eg butter, milk, cream, cheese and ice cream — you can substitute cow's milk with soy milk and eat less acidic cheeses such as feta and goat's cheese
• Oil, fatty foods and fried foods 
• Certain vegetables and herbs ie garlic, onions, peppermint and spearmint

Other acidic foods include spicy foods and meals containing lots of tomatoes eg spaghetti sauce, pizza, chilli con carne and salsa.

A hernia is when part of an organ pushes through a wall of muscle that is holding it in place. There are different types of hernia. Two of the most common types of hernia are: 

• Hiatus hernia — part of an organ pushes through your diaphragm; most commonly part of your stomach or small intestine pushes through but in some cases, it may be your pancreas or spleen 
• Inguinal hernia — part of your lower bowel pushes through the muscle in your groin

There are two main types of hiatus hernia:

Sliding hiatus hernia

This is the most common type of hiatus hernia, accounting for around 95% of hiatus hernia cases. It occurs when the sphincter at the bottom of your gullet pushes through your hiatus and regularly slides in and out of your lower chest. This type of hernia is usually small and causes acid reflux.

Para-oesophageal hiatus hernia

This is also called a rolling hiatus hernia and only accounts for around 5% of hiatus hernia cases. It occurs when part of your stomach pushes through your hiatus. In some cases, your pancreas, spleen or small intestine may push through instead.

A para-oesophageal hiatus hernia comes with a risk of the organ that is pushing through getting stuck, which causes a blockage. If part of your stomach (or another organ) gets stuck and squeezed, its blood supply can be severely reduced — this is called a strangulated hernia.

A hiatus hernia is often symptomless and won’t give you any problems.

If symptoms do occur, it is usually caused by acid reflux, when stomach acid and/or food in your stomach flows backwards into your gullet. This can happen because your hiatus hernia causes your sphincter to stop working properly or causes loss of the normal pressure applied by your diaphragm onto your gullet.

However, if you have acid reflux, it does not mean you have a hiatus hernia. Conversely, if you have a hiatus hernia, you may not have acid reflux — although you are more likely to develop problems with your sphincter, which can trigger acid reflux and heartburn. 

The most common symptom of a hiatus hernia is heartburn, which is sometimes caused by GORD. Other hiatus hernia symptoms include:

• A sour taste at the back of your mouth 
• Bad breath 
• Breathlessness
• Burping, bloating, nausea and/or vomiting 
• Difficulty swallowing and/or regurgitation of food
• Indigestion 

You may also experience chest pain and/or stomach pain that comes and goes, and is often worse after eating a meal.

Rare symptoms of a hiatus hernia can sometimes mimic other conditions. These symptoms include: 

• A persistent cough, especially at night — acid from acid reflux can irritate your windpipe (trachea) causing coughing and wheezing, similar to asthma
• Mouth and throat symptoms — this includes: 
• A sore throat 
• Feeling like you have a lump in your throat 
• Gum problems 
• Hoarseness
• Severe stomach or chest pain, with retching or vomiting — this can occur if you have a para-oesophageal hiatus hernia and part of your gut becomes stuck and blocked

Occasionally, heartburn caused by a hiatus hernia can trigger severe chest pain. It can be difficult to distinguish chest pain associated with a hiatus hernia from a heart attack, so if you do have chest pain, seek medical attention immediately.

You should also seek urgent medical attention if you have a hiatus hernia and any of the below symptoms: 

• An upset stomach 
• Can't pass a stool or gas 
• Severe stomach or chest pain  
• Vomiting

These symptoms could be signs of a strangulated hernia, which is a medical emergency.

If your hiatus hernia symptoms, such as heartburn, chest pain or stomach pain, continue for over three weeks and over-the-counter medication isn’t helping, see your GP.

Your GP will discuss your symptoms and your general health. Your GP may refer you to a gastroenterologist (a consultant specialising in the digestive system) for further assessment and treatment.

The tests you may need include:

• Barium swallow test — drinking a chalky liquid before having a series of X-rays to identify any problems in your digestive system
• Gastroscopy (endoscopy) — a tiny camera that films inside your stomach and gullet 
• Oesophageal manometry — this measures the pressure in your gullet and at the sphincter between your gullet and stomach

It’s unclear what the causes of a hiatus hernia are, but it may be:

• Weakening of your diaphragm as you age, allowing the stomach to squeeze through 
• Repeated, intense pressure on the muscles around your gullet and/or stomach eg from coughing, exercising, often lifting heavy objects, straining when passing stools and vomiting 
• Obesity
• Family history of hiatus hernia 
• Injury or an operation near your stomach or oesophagus 
• Scoliosis or kyphosis — a curved spine

You are also at greater risk of developing a hiatus hernia if you are born with an unusually large hiatus.  

Hiatus hernia doesn’t often cause symptoms and therefore, in these cases, doesn’t need treatment. However, if you have persistent or recurrent symptoms (eg heartburn, acid reflux), see your GP for advice on appropriate treatment. 

They may suggest simple changes that you can try at home, such as:

• Avoiding bending over, lying down or lifting heavy objects immediately after eating or drinking
• Having smaller, more frequent meals and chewing your food properly
• Identifying the foods that trigger heartburn related to hiatus hernia — foods to avoid often include fatty, spicy and fried foods 
• Living a healthier life — stop smoking, don’t drink too much alcohol, lose any excess weight and take time to relax 
• Raising the head of your bed so you’re slightly tilted when sleeping

Hiatus hernia medication

Over-the-counter medications, such as antacids that neutralise stomach acid, can help relieve your hiatus hernia symptoms, especially heartburn and acid reflux. Alternatively, your GP or consultant may prescribe a short course of medication to reduce the production of stomach acid or stop acid production and help your gullet heal.

Hiatus hernia surgery

If lifestyle changes and medication are unsuccessful and your symptoms are very severe eg you have severe inflammation or narrowing of your gullet, your GP or consultant may suggest surgery.

A hiatus hernia surgery is usually done as a keyhole (laparoscopic) surgery and has a good success rate. This may involve a procedure called a fundoplication, where the top part of your stomach (the fundus) is wrapped around part of your gullet. Hiatus hernia surgery is also, less commonly, performed as an open surgery.

Whether your surgery is keyhole or open, the procedure usually takes two to three hours and is always performed under general anaesthesia. Further surgery may be needed if your hiatus hernia returns.

Hiatus hernia doesn’t usually cause complications. However, in rare cases, you may develop complications from the stomach acid leaking into your gullet and causing changes in the cells of your gullet. 

You may develop a persistent cough if your acid reflux irritates your voice box (larynx) — this can usually be treated with anti-reflux medication.

Leaking stomach acid can also cause Barrett's oesophagus, a condition where changes occur in the cells that line the lower part of your gullet, which make these cells more likely to become cancerous. Around one in 20 men and one in 33 women with Barrett's oesophagus develop oesophageal cancer. Long-term acid reflux and a hiatus hernia, together, therefore increase your risk of oesophageal cancer.

You may also develop inflammation of your gullet (oesophagitis) due to acid reflux, which can be treated with proton pump inhibitors (PPIs). In rare cases, long-term inflammation of your gullet can lead to an oesophageal stricture ie narrowing of your gullet.

If you have a para-oesophageal hernia, there is a small risk of developing a twisting of your gut (volvulus) or a strangulated hernia.