Hiatus hernia: what it is, symptoms and treatment

A hiatus hernia (hiatal hernia in the US) is when part of the stomach pushes up through the diaphragm into the chest. It is very common, especially over the age of 50, and many people who have one never know.

What is it?

The oesophagus passes through a gap in the diaphragm, called the hiatus, to reach the stomach. Normally the diaphragm squeezes around this point and helps the lower oesophageal sphincter keep acid in the stomach. In a hiatus hernia, the top of the stomach slides up through the gap. This separates the two parts of the barrier and makes reflux more likely.

• Sliding hiatus hernia: by far the most common type. The junction between the oesophagus and stomach slides up into the chest, sometimes moving up and down.
• Para-oesophageal hiatus hernia: less common. Part of the stomach squeezes up alongside the oesophagus. Large ones can occasionally twist or become trapped, which is an emergency.

Causes and risk factors

It is not always clear why one develops. Risk factors include getting older, carrying extra weight, pregnancy, and anything that repeatedly raises pressure in the abdomen, such as chronic coughing, straining or heavy lifting.

Symptoms

Small hiatus hernias often cause no symptoms. When they do, the symptoms are usually those of reflux: heartburn, regurgitation, a sour taste, burping and discomfort in the chest or upper abdomen, often worse after meals and when lying down. Larger hernias can also cause difficulty swallowing, feeling full quickly or breathlessness after eating.

How it is found

A hiatus hernia is usually found during an endoscopy, a barium swallow X-ray or a CT scan, often when looking for the cause of reflux.

Treatment

Most people do not need treatment for the hernia itself. Treating the reflux it causes is usually enough: the lifestyle changes that help reflux (smaller meals, not eating late, raising the head of the bed, losing weight) and, if needed, medicines such as PPIs.

Surgery to repair the hernia, usually together with a fundoplication to strengthen the valve, may be recommended for people with a large hernia and reflux that does not respond to medicine, severe oesophagitis, or a para-oesophageal hernia causing symptoms.