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 stomach, squeezes through the hiatus.

A hiatus hernia can affect the diaphragm’s ability to stop stomach acid 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 has a hiatus hernia. You’re also more likely to develop a hiatus hernia if you’re overweight or pregnant.

In many cases, a hiatus hernia doesn’t need treatment — 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 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.

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

The most common type is a sliding hiatus hernia. It occurs when the sphincter at the bottom of your gullet pushes through your hiatus and slides in and out of your lower chest. This type of hernia is usually small and causes acid reflux. 

A para-oesophageal hiatus hernia, which is also called a rolling hiatus hernia, is much less common. 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 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. Other hiatus hernia symptoms include:

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

You may also have pain in your chest and stomach. Symptoms often come and go and tend to be 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
• Bad breath
• 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 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:

• Gastroscopy (endoscopy) – a tiny camera that films inside your stomach and gullet
• Barium swallow test – drinking a chalky liquid before having a series of X-rays to identify any problems in your digestive system

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 heavy lifting or coughing
• Obesity
• Family history of hiatus hernia
• Injury or an operation near your stomach or oesophagus
• Scoliosis or kyphosis – a curved spine

There are several ways you can help relieve hiatus hernia symptoms. These include:

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

Over-the-counter medications such as antacids may successfully relieve your hiatus hernia symptoms, especially heartburn. Alternatively, your GP or consultant may prescribe a short course of medication to suppress or reduce the production of stomach acid.

If lifestyle changes and medication are unsuccessful and your symptoms are very severe, your GP or consultant may suggest surgery. A hiatus hernia operation is usually done as keyhole (laparoscopic) surgery and has a good success rate. However, further surgery may be required if the hiatus hernia returns.

• A persistent cough — this is caused by the acid from acid reflux irritating your voice box (larynx); it can be treated with anti-reflux medication
• Barrett's oesophagus — changes 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 
• Cancer — long-term acid reflux slightly increases your risk of oesophageal cancer; long-term acid reflux and a hiatus hernia further increases your risk as acid reflux is usually worse in people with a hiatus hernia
• Narrowing of your gullet (oesophageal stricture) — severe long-term inflammation of your gullet can cause scarring and narrowing; this is rare
• Oesophagitis — inflammation of the lining of your gullet, which is caused by the acid from acid reflux irritating it; it can be treated with PPIs
• Twisting of your gut (volvulus) or a strangulated hernia — these can occur if you have a para-oesophageal hernia but are rare