Hiatus Hernia

What is a Hiatus Hernia?

A hiatus hernia occurs when part of the stomach pushes upward through the diaphragm and into the chest cavity. The diaphragm is a large muscle that separates the chest from the abdomen and helps with breathing. Normally, the oesophagus passes through a small opening in the diaphragm called the hiatus before connecting to the stomach. In a hiatus hernia, the stomach bulges through this opening.

Impact of Hiatus Hernia on Anatomy and Health

The oesophagus and stomach normally work together to move food smoothly into the digestive system. The lower oesophageal sphincter (LES), a ring-like muscle at the junction of the oesophagus and stomach, acts as a valve to prevent stomach acid from flowing backward.

A hiatus hernia can disrupt this normal anatomy and function.

• Displacement of the Stomach: Part of the stomach moves into the chest cavity, which alters the natural alignment between the oesophagus and stomach.
• Weakened Acid Barrier: The lower oesophageal sphincter may not close properly, allowing stomach acid to travel back into the oesophagus.
• Increased Acid Reflux: Acid reflux can irritate the lining of the oesophagus and lead to symptoms such as heartburn and chest discomfort.
• Inflammation of the Oesophagus: Long-term reflux can cause inflammation known as oesophagitis.
• Complications in Severe Cases: Large para-oesophageal hernias may lead to obstruction of the stomach, impaired blood supply, or twisting of the stomach.

Over time, untreated reflux due to a hiatus hernia may contribute to complications such as oesophageal ulcers, narrowing of the oesophagus (strictures), or changes in the oesophageal lining.

Risk Factors for Hiatus Hernia

While the condition can occur in anyone, it is more common in particular groups of people.

• Older Adults: The risk increases with age as the diaphragm muscles naturally weaken over time.
• People Who Are Overweight or Obese: Increased abdominal pressure can push the stomach upward through the diaphragm.
• Individuals with Chronic Coughing: Persistent coughing can increase pressure within the abdomen.
• People Who Frequently Strain: Heavy lifting or straining during bowel movements can contribute to hernia formation.
• Pregnant Women: Increased abdominal pressure during pregnancy may increase the risk.
• People with a Family History of Hernias: Some individuals may have a naturally larger hiatus opening or weaker connective tissues.
• Individuals with Long-standing Acid Reflux: Chronic reflux may contribute to weakening of the structures around the oesophageal opening.

Although many hiatus hernias develop gradually over time, sudden increases in abdominal pressure can sometimes trigger the condition.

Causes of Hiatus Hernia

A hiatus hernia usually develops when the tissues and muscles around the oesophageal opening in the diaphragm become weakened. This allows part of the stomach to push upward through the hiatus.

Common contributing factors include:

• Weakening of the Diaphragm with Age: As people get older, the diaphragm muscles may become less strong and more prone to stretching.
• Increased Pressure Inside the Abdomen: Pressure from obesity, pregnancy, heavy lifting, or chronic straining can push the stomach upward.
• Congenital Factors: Some people are born with a larger-than-normal hiatus opening.
• Trauma or Injury: Injury to the diaphragm or previous abdominal surgery can contribute to the development of a hiatus hernia.
• Chronic Coughing or Vomiting: Repeated pressure from coughing or vomiting may weaken the diaphragm over time.
• Connective Tissue Weakness: Some individuals have naturally weaker connective tissues that make hernias more likely.

Symptoms of Hiatus Hernia

Many small hiatus hernias do not cause symptoms and may only be discovered incidentally during medical tests. When symptoms do occur, they are usually related to acid reflux.

Common symptoms include:

• Heartburn: A burning sensation in the chest caused by stomach acid entering the oesophagus.
• Acid Regurgitation: Sour or bitter fluid rising into the throat or mouth.
• Chest Pain or Discomfort: This may sometimes mimic heart-related chest pain.
• Difficulty Swallowing (Dysphagia): Food may feel as though it becomes stuck in the oesophagus.
• Persistent Burping or Bloating: Excess gas may build up due to reflux and digestive disruption.
• Chronic Cough or Hoarseness: Acid reflux can irritate the throat and voice box.
• Feeling of Fullness After Eating: Pressure in the chest or upper abdomen may occur after meals.

In more serious cases, particularly with para-oesophageal hernias, symptoms may include severe chest pain, vomiting, or difficulty eating. These situations may require urgent medical attention.

Preventing Hiatus Hernia

Not all hiatus hernias can be prevented, particularly those related to ageing or inherited anatomical factors. However, certain lifestyle habits may help reduce the risk or prevent symptoms from worsening.

• Maintain a Healthy Weight: Reducing excess body weight lowers pressure on the abdomen and diaphragm.
• Avoid Heavy Straining: Using proper lifting techniques and avoiding excessive strain can help protect the diaphragm.
• Manage Chronic Coughing: Treating underlying respiratory conditions may reduce repeated pressure on the diaphragm.
• Prevent Constipation: Eating fibre-rich foods and staying hydrated can reduce straining during bowel movements.
• Eat Smaller Meals: Large meals increase stomach pressure and can worsen reflux.
• Avoid Trigger Foods: Fatty foods, alcohol, caffeine, and spicy foods can worsen reflux symptoms.
• Stop Smoking: Smoking can weaken the lower oesophageal sphincter and increase reflux.
• Avoid Lying Down Immediately After Eating: Remaining upright for at least two to three hours after meals helps digestion and reduces reflux.
• Strengthen Core and Postural Muscles: Good posture and core strength may reduce pressure on the diaphragm.

While these strategies cannot always prevent the condition entirely, they can significantly reduce symptoms and improve digestive health.

Types of Hiatus Hernia

Hiatus hernias are generally classified based on how the stomach moves through the diaphragm and the relationship between the stomach and oesophagus.

• Type I – Sliding Hiatus Hernia: This is the most common type, accounting for around 90–95% of cases. In a sliding hernia, the junction between the oesophagus and stomach (gastro-oesophageal junction) moves upward into the chest through the diaphragm. The stomach may slide up and down depending on body position or abdominal pressure. Sliding hernias are often associated with acid reflux and gastro-oesophageal reflux disease (GERD).
• Type II – Para-Oesophageal Hernia: In this type, the gastro-oesophageal junction remains in its normal position, but part of the stomach pushes through the diaphragm next to the oesophagus. Although less common, this type can be more serious because the portion of the stomach in the chest may become trapped or lose its blood supply.
• Type III – Mixed Hernia: This type combines features of both sliding and para-oesophageal hernias. Both the gastro-oesophageal junction and part of the stomach move into the chest cavity. These hernias are usually larger and may produce more severe symptoms.
• Type IV – Complex Hernia: This is the most advanced and least common form. A large portion of the stomach moves into the chest, and sometimes other abdominal organs, such as the colon, spleen, or small intestine, may also herniate through the diaphragm.

Each type differs in severity and risk of complications. Sliding hernias usually cause reflux symptoms, while para-oesophageal hernias are more likely to cause mechanical problems such as obstruction or strangulation of the stomach.

Diagnosis of Hiatus Hernia

A hiatus hernia is often diagnosed when patients are investigated for symptoms such as persistent reflux, chest discomfort, or difficulty swallowing. Several diagnostic tests may be used to confirm the presence of the hernia and assess its severity.

• Medical History and Physical Examination: A doctor will review symptoms, lifestyle factors, and medical history. Although a hiatus hernia cannot usually be detected on physical examination, symptoms may suggest it.
• Upper Endoscopy (Gastroscopy): A thin flexible tube with a camera is inserted through the mouth into the oesophagus and stomach. This allows doctors to directly examine the oesophagus, identify the hernia, and check for inflammation or complications such as ulcers.
• Barium Swallow X-ray: Patients drink a liquid containing barium, which coats the digestive tract and makes it visible on X-rays. This test clearly shows the shape of the oesophagus and stomach and can reveal the presence and size of a hiatus hernia. 
• Oesophageal Manometry: This test measures the strength and coordination of the oesophageal muscles and the lower oesophageal sphincter. It helps assess how well the oesophagus moves food toward the stomach.
• 24-Hour pH Monitoring: A small probe is used to measure acid levels in the oesophagus over a 24-hour period. This test helps determine whether reflux related to a hiatus hernia is causing symptoms.

Treatment for Hiatus Hernia

Many cases can be managed without surgery.

• Lifestyle and Dietary Changes: These measures are often the first step in managing symptoms.
• Weight management: Reducing excess body weight helps decrease abdominal pressure.
• Eating smaller meals: Large meals increase pressure within the stomach.
• Avoiding reflux-triggering foods: Spicy foods, fatty foods, caffeine, and alcohol may worsen reflux.
• Elevating the head of the bed: This may help reduce nighttime reflux symptoms.
• Medications: Medications may be prescribed to reduce stomach acid and relieve reflux symptoms.
• Antacids: Provide quick relief by neutralising stomach acid.
• H2 receptor blockers: Reduce acid production.
• Proton pump inhibitors (PPIs): Strong acid-suppressing medications that allow the oesophagus to heal.
• Surgical Treatment: Surgery may be recommended if symptoms are severe, persistent, or if complications occur.

Common surgical procedures include:

• Hiatus Hernia Repair: The stomach is repositioned into the abdomen, and the opening in the diaphragm is tightened.
• Fundoplication: The upper part of the stomach is wrapped around the lower oesophagus to strengthen the valve that prevents reflux.
• Laparoscopic Surgery: Most procedures are performed using minimally invasive techniques through small incisions, allowing faster recovery and less postoperative discomfort.

Surgery is particularly important for para-oesophageal hernias because of the risk of the stomach becoming trapped or losing its blood supply.

What if a Hiatus Hernia is Untreated?

Many small hiatus hernias cause minimal symptoms and may not require treatment. However, if the condition worsens or symptoms are ignored, complications may develop.

• Chronic Acid Reflux (GERD): Ongoing reflux can irritate and damage the oesophageal lining.
• Oesophagitis: Persistent inflammation of the oesophagus caused by stomach acid.
• Oesophageal Ulcers: Open sores may develop in the oesophagus due to prolonged acid exposure.
• Oesophageal Strictures: Scar tissue can cause narrowing of the oesophagus, making swallowing difficult.
• Barrett’s Oesophagus: Long-term reflux can cause changes in the cells lining the oesophagus, increasing the risk of oesophageal cancer.
• Stomach Obstruction: In para-oesophageal hernias, the stomach may become trapped in the chest cavity.
• Strangulation of the Stomach: The blood supply to part of the stomach may become cut off, which is a medical emergency requiring urgent surgery.

For these reasons, persistent reflux symptoms, difficulty swallowing, or chest discomfort should always be evaluated by a doctor.

Early diagnosis and appropriate management can prevent complications and significantly improve quality of life.