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Hiatal Hernia

  • Definition

    A hiatal hernia occurs when the upper part of your stomach protrudes into your chest cavity through a weakness in the hiatus (opening) in your diaphragm.


    Hiatal hernias are common, especially among people who are overweight. In most instances, a hiatal hernia causes no symptoms and is of no significance. You may not even know that you have one, unless your doctor discovers it after a routine x-ray.

    On the other hand, you may be all too familiar with one of its most common symptoms: gastresophageal reflux (see the health profile gastroesophageal reflux disease - GERD). This is a burning sensation that radiates upward from your lower chest or upper abdomen, or an unpleasant regurgitation that occurs when you lie down or bend over.

    Doctors believe a hiatal hernia may contribute to reflux (backward flow) of stomach contents. A sphincter (ring-like muscle) separates your stomach from your esophagus. Think of this muscle as a rubber band that constricts to form a one-way valve, preventing stomach contents from refluxing. As the pressure in your stomach increases, it can overcome the pressure exerted by the sphincter - much like stretching a rubber band - allowing the reflux to occur.

    Whether or not you need to see a doctor for a hiatal hernia depends on the severity of your symptoms. Occasional reflux of stomach contents commonly occurs in almost everyone, however, a hiatal hernia can increase the amount or frequency of reflux, making it more likely for you to have heartburn.

    If you smoke, are overweight or eat certain foods that contribute to acid backup, your symptoms may be worse. Frequent reflux of stomach contents can lead to esophagitis, an inflammation of the lining of the esophagus. When severe, esophagitis can cause a stricture (narrowing) of the esophagus. A stricture makes swallowing of food difficult or painful.


    The most frequent cause of hiatal hernia is an increased pressure in the abdominal cavity produced by coughing, vomiting, straining at stool or sudden physical exertion. pregnancy, obesity or excess fluid in the abdomen also contribute to this condition.


    If you have a hiatal hernia, your doctor will probably suggest one of these three approaches to manage your condition:

    No treatment - if you do not have any symptoms from a hiatal hernia, and most people do not, you probably do not need to do anything about it.

    A combination of lifestyle changes and medications - if you have recurrent gastroesophageal reflux, eliminating coffee, alcohol and smoking, combined with weight reduction if you are overweight, may do a great deal to relieve the heartburn and prevent esophagitis.

    The great majority of patients can be managed by a conservative program. Every effort must be made to enlist the aid of gravity in preventing reflux at night. The patient should not lie down after meals and should not eat a late meal before bedtime. The head of the patient's bed should be elevated on six inch blocks; attempting to sleep propped up on pillows almost never succeeds.

    Also, antacids or antacid combinations containing alginic acid can help neutralize stomach acid. If these changes do not help, your doctor may prescribe drugs such as cimetidine, ranitidine or omeprazole to reduce stomach acid secretion.

    Surgery - when severe symptoms of reflux persist despite the combination of lifestyle changes and medications, or if the complications such as stricture, chronic bleeding or obstruction develop, surgery may be necessary. The surgeon's goal is to "rebuild" the esophageal sphincter and repair the hernia.

    There are two types of esophageal hiatal hernia: paraesophageal and sliding. Symptoms from an uncomplicated paraesophageal hernia usually develop in adult life and may consist of a sense of pressure in the lower chest after eating and occasionally palpitations, due to cardiac arrhythmias. All of these are pressure phenomena, caused by the enlargement of the herniated gastric pouch when food displaces the fundic (stomach’s) air bubble.

    Since complications are frequent in paraesophageal hiatal hernias, even in the absence of symptoms, operative repair is indicated in most cases. The usual method is to return the herniated stomach to the abdomen and affix it with sutures to the posterior rectus sheath (anterior gastroplexy). The enlarged hiatus is closed snugly around the gastroesophageal junction with interrupted sutures. It is unnecessary to excise (cut out) the hernia sac. The results of surgical management are generally excellent.

    Most patients (80 percent) with clinically significant reflux have a sliding hiatal hernia. In these patients, the cardioesophageal junction and the fundus of the stomach are displaced upward into the posterior mediastinum, exposing the lower esophageal sphincter to intrathoracic pressure. At least half of all sliding hiatal hernias are asymptomatic and require no treatment.


    Are any tests needed to diagnose the problem?

    How serious is the problem?

    What type of treatment will you recommend?

    What results should be expected from this treatment?

    If a "wait and see" decision is made, will the hiatal hernia become worse?

    What are the chances surgery will be required?

    What can be expected from the surgery?