Hiatal hernia

A hiatal hernia happens when part of your stomach moves upward through an opening in your diaphragm. The diaphragm is the broad muscle beneath your lungs that separates your chest from your abdomen and helps you breathe.

Your food pipe, called the esophagus, normally passes through a small opening in the diaphragm called the hiatus before joining the stomach. If this opening widens or the surrounding tissue weakens, part of the stomach can move through it.

There are two main types:

• Sliding hiatal hernia: The junction between the esophagus and stomach slides above the diaphragm. This is the most common type and is often small.
• Paraesophageal hiatal hernia: Part of the stomach moves beside the esophagus while the stomach-esophagus junction stays closer to its usual position. Large hernias may include both patterns.

Many hiatal hernias cause no symptoms and are found during a test performed for another reason. When symptoms occur, they often come from gastroesophageal reflux, when stomach contents flow backward into the esophagus. Larger hernias can also cause pressure, trouble eating, or less commonly, blockage and reduced blood flow to the stomach.

A small sliding hiatal hernia may not cause any noticeable problems. Having a hernia does not automatically mean that you will have reflux.

Possible symptoms include:

• Burning behind the breastbone, known as heartburn
• Sour or bitter fluid coming into the throat or mouth
• Upper abdominal or chest discomfort
• Trouble swallowing or a feeling that food is sticking
• Belching, bloating, or feeling full soon after starting a meal
• Symptoms that worsen after meals, when bending over, or when lying down
• Cough, hoarseness, or throat irritation linked to reflux
• Shortness of breath after eating, particularly with a large hernia

A large paraesophageal hernia may cause pressure after meals, early fullness, nausea, or difficulty eating enough. Slow bleeding from irritated stomach tissue can sometimes lead to anemia, meaning too few healthy red blood cells. This may cause tiredness, weakness, or breathlessness.

Chest pain should not automatically be blamed on a hiatal hernia. Heart and lung conditions can cause similar symptoms and may need urgent assessment.

The exact reason a hiatal hernia develops is often unclear. The tissue holding the stomach and esophagus in place may weaken or stretch over time. Pressure inside the abdomen can then push the stomach upward through the hiatus.

Factors associated with hiatal hernia include:

• Increasing age and age-related tissue changes
• Higher pressure in the abdomen from excess body weight
• Pregnancy
• Repeated heavy straining, coughing, or vomiting
• Injury or previous surgery around the diaphragm
• Differences in the diaphragm present from birth
• Some conditions that affect the strength of connective tissue

These factors do not mean that someone caused their hernia. Ordinary activities may reveal an existing weakness rather than create one by themselves.

A hiatal hernia may be found while investigating heartburn, swallowing difficulty, chest discomfort, anemia, or another problem. It may also appear unexpectedly on an X-ray or scan.

Tests that can show a hiatal hernia include:

• Upper endoscopy: A thin, flexible camera is passed through the mouth to examine the esophagus and stomach. It can also show inflammation, narrowing, ulcers, or bleeding.
• Contrast swallow: You drink a liquid, usually containing barium, that outlines the esophagus and stomach on X-rays. This can show the hernia's size and how swallowing is affected.
• CT or other chest imaging: These scans may identify a large hernia or help assess a possible complication.

Other tests may be used when symptoms do not clearly match the findings. Esophageal manometry measures how the esophagus and its valve work. Reflux monitoring measures how often stomach contents enter the esophagus. These tests assess related problems rather than simply confirming that a hernia exists.

The size seen during testing can change because sliding hernias move with swallowing, breathing, and body position. Test results therefore need to be considered alongside your symptoms.

A hiatal hernia that causes no symptoms often needs no treatment. Treatment does not usually aim to push a small sliding hernia permanently back into place. Instead, it focuses on controlling reflux and protecting the esophagus.

Measures that may reduce reflux include eating smaller meals, avoiding lying down soon after eating, and raising the head of the bed if symptoms occur at night. If excess body weight is contributing to reflux, gradual weight loss may help. Foods and drinks are best limited only when they reliably trigger your symptoms; there is no single hiatal hernia diet.

Medicines used for reflux include:

• Antacids, which briefly neutralize stomach acid
• H2 blockers, which reduce acid production
• Proton pump inhibitors like omeprazole or lansoprazole, which suppress acid more strongly and allow irritated tissue to heal

These medicines treat acid reflux, not the opening in the diaphragm. The most suitable type and length of treatment depend on symptom frequency, test findings, other health conditions, and other medicines you take.

Surgery may be considered when a hernia causes significant mechanical symptoms, obstruction, bleeding, or reduced blood flow. It may also be an option for troublesome reflux that remains inadequately controlled despite appropriate treatment, or when a large paraesophageal hernia is affecting eating or breathing.

During surgery, the stomach is returned to the abdomen and the opening in the diaphragm is narrowed. The surgeon may also create a wrap around the lower esophagus to reduce reflux or secure the stomach in position. Surgery has possible risks, and a hernia or reflux can return afterward. The decision is based on the hernia's type, symptoms, overall health, and expected benefits.

Most small hiatal hernias do not cause serious complications. Problems are more likely when reflux is persistent or the hernia is large.

Repeated acid exposure can inflame the esophagus, cause ulcers, or produce scar tissue that narrows the passage. Long-standing reflux is also associated with Barrett's esophagus, a change in the lining of the lower esophagus that requires appropriate follow-up.

A large hernia may cause:

• Slow bleeding and iron-deficiency anemia
• Food becoming held up in the stomach
• Breathing discomfort or food entering the airway
• Twisting of the stomach, called gastric volvulus
• Trapping of the stomach with loss of its blood supply, called strangulation

Twisting, complete blockage, and strangulation are uncommon but require urgent treatment. Warning signs can include sudden severe chest or upper abdominal pain, repeated retching or vomiting, marked swelling, and inability to swallow.

A hiatal hernia cannot always be prevented. Tissue strength, anatomy, aging, pregnancy, and inherited characteristics cannot be fully controlled.

Reducing prolonged pressure within the abdomen may lower strain on the diaphragm, but it does not guarantee prevention. This can include managing constipation, seeking help for a long-lasting cough, using safe lifting methods, and maintaining a weight that is appropriate for you.

If you already have a hiatal hernia, these steps may reduce reflux or pressure-related symptoms. They do not reliably close the opening or reverse the hernia.

Many people live for years with a small hiatal hernia without knowing it is present. When reflux is the main problem, symptoms often improve with practical changes and acid-reducing treatment. The hernia itself may remain, even when symptoms settle.

Symptoms can come and go. Large meals, lying down after eating, weight changes, pregnancy, and medicines that affect digestion may influence how you feel. A sliding hernia can also move in and out of the chest, so it may look different on separate tests.

Routine follow-up may be appropriate if you need ongoing reflux medicine, have inflammation or narrowing of the esophagus, or develop recurring symptoms. Barrett's esophagus, if found, has its own monitoring plan.

Larger paraesophageal hernias may stay stable, but some gradually produce more fullness, swallowing difficulty, anemia, or breathing discomfort. New or changing symptoms should be reviewed rather than assumed to be harmless.

Recovery after surgery commonly includes a gradual return to normal eating and activity. Temporary swallowing difficulty, bloating, or reduced ability to belch can occur. Repair is often effective, but symptoms or the hernia can return over time.

Arrange a routine medical appointment if you have frequent heartburn, repeated regurgitation, ongoing upper abdominal discomfort, or symptoms that disturb sleep despite self-care. Also seek assessment for gradually worsening swallowing difficulty, unexplained tiredness, early fullness, or recurring vomiting.

Get prompt medical advice if food repeatedly sticks, swallowing becomes painful, you are losing weight without intending to, or you develop signs of anemia such as unusual fatigue, weakness, or breathlessness.

Seek emergency help for:

• New, severe, or persistent chest pain, especially with sweating, faintness, breathlessness, or pain spreading to the arm, back, neck, or jaw
• Sudden severe chest or upper abdominal pain
• Repeated retching or vomiting with an inability to keep fluids down
• Vomiting blood or material resembling coffee grounds
• Black, sticky stools, particularly with weakness or dizziness
• Severe pain with inability to swallow, marked abdominal swelling, or collapse

These symptoms can have causes other than a hiatal hernia. Emergency assessment is important because symptoms of a heart problem, internal bleeding, or a trapped stomach can overlap.

Can a hiatal hernia go away by itself?

An adult hiatal hernia does not usually close by itself. A sliding hernia can move above and below the diaphragm, so it may not be visible on every test. Symptoms may disappear even though the underlying opening remains wider than usual.

Do I need surgery for a hiatal hernia?

Most people with a small sliding hernia do not need surgery. Surgery is mainly considered for significant reflux that has not responded adequately to treatment, mechanical symptoms from a large hernia, or complications such as obstruction or bleeding.

What foods should I avoid with a hiatal hernia?

There is no universal list. Common reflux triggers include large or high-fat meals, alcohol, and foods that are spicy or acidic, but not everyone reacts to them. Focus on foods that repeatedly cause your own symptoms rather than restricting your diet unnecessarily.

Can I exercise with a hiatal hernia?

Many people can exercise normally. Activity may also support weight management and general health. Bending, heavy straining, or exercising soon after a meal can worsen symptoms for some people. Stop and seek assessment if activity causes chest pain, severe discomfort, faintness, or unusual breathlessness.

Is hiatal hernia the same as acid reflux?

No. A hiatal hernia is a change in the position of the stomach. Acid reflux is the backward movement of stomach contents into the esophagus. A hernia can make reflux more likely, but either can occur without the other.

Can a hiatal hernia cause heart palpitations?

Palpitations are not a typical direct symptom. Reflux, discomfort, anxiety, or pressure from a large hernia may create sensations that feel similar. New or persistent palpitations, especially with chest pain, faintness, or breathlessness, should be medically assessed.