In this article, we explain the causes and symptoms of a hiatal hernia and the treatment options available.
What is a hiatal hernia?
A hiatal hernia rarely causes symptoms, but might cause heartburn.
A hiatal hernia develops when body tissue or an organ pushes through the diaphragm. The diaphragm is a membrane that keeps the organs of the abdomen in place, separating them from the heart and lungs in the chest cavity.
It is a dome-shaped, muscular layer between the two cavities, and it moves up and down to support breathing.
The diaphragm has a smooth surface with no open holes, but key structures and vessels run through it. The largest of these structures is the food pipe, which is also called the esophagus. The food pipe connects the back of the mouth to the stomach, and it is essential for pushing food down for digestion.
Just above the stomach, the diaphragm usually surrounds the food pipe tightly to keep the abdominal organs and tissues in place. This narrowing of the food pipe helps prevent the contents of the stomach from moving back up into the chest section of the food pipe.
A hiatal hernia occurs when part of the upper stomach pushes through the diaphragm at this point.
Causes and risk factors
The causes of the structural weaknesses that lead to a hiatal hernia are not clear. One potential cause might be pressure on the diaphragm, the risk of which may be higher in some people due to certain genetic factors.
Several risk factors make a weakening of the hiatus, an opening in the diaphragm through which the food pipe passes, more likely. For example, hiatal hernias are more common among people over 50 years of age and those who have obesity.
Other risk factors include an upward force that occurs due to weightlifting, straining to empty the bowel, or persistent coughing or vomiting. These actions temporarily increase the pressure inside the abdominal cavity.
A hiatal hernia often occurs in women during pregnancy. The growing fetus pushes the abdominal organs upward, sometimes causing them to bulge through the diaphragm where it meets the food pipe.
A congenital anomaly in the diaphragm is another cause, but this type of hiatal hernia is rare.
Injury to the diaphragm, such as trauma from a fall or traffic accident, can also lead to a hiatal hernia. Some surgical procedures involving the food pipe also increase a person's risk.
A hiatal hernia often causes no symptoms. As a result, a medical professional will typically detect this type of hernia by chance when a person receives a scan for another reason.
Two main types of hiatal hernia can occur. Sliding hiatal hernias are the most common type, and they are usually small. These hernias do not stay in a fixed position but move up and down.
Fixed or rolling hiatal hernias are less common. These still bulge through the diaphragm but remain still.
Both types often do not cause symptoms. When people with hiatal hernias do experience symptoms, these are usually the result of acid moving up from the stomach. This acid can cause heartburn, which is a burning sensation around the lower chest area.
Heartburn tends to get worse in response to certain foods and beverages, and it often occurs when a person is lying down or bending over, especially soon after eating. It can lead to bloating, belching, and a bad taste in the back of the throat.
If heartburn becomes a regular problem, this might signify that a person has acid reflux. Acid reflux is a condition in which heartburn occurs at least twice a week.
If acid reflux happens too regularly for a prolonged period, it might progress to gastroesophageal reflux disease.
As obesity is a risk factor for a hiatal hernia, weight loss could help reduce the risk for some people. The other known causes and risk factors of these hernias are not preventable.
Controlling portion size can help prevent heartburn.
Anyone who has a hiatal hernia may find that making changes to their diet and drinking habits can help reduce heartburn symptoms. A person is likely to benefit from decreasing the following:
- overall meal size
- portion size
- consumption of specific foods that trigger reflux
Reducing the intake of the following foods and beverages can often help minimize symptoms:
- fatty or spicy foods
The timing of eating and drinking can also be a factor because mealtimes affect when acid might flow back into the food pipe.
People who experience heartburn should sit upright while eating and have their meals at least 3 hours before lying down to sleep.
Raising the head end of the mattress so that the bed slopes slightly down toward the feet might also help reduce symptoms. However, the whole body needs to be at an incline, not just the head.
Several different treatment options are available for people who develop a hiatal hernia.
Treatments to relieve acid reflux symptoms are available over the counter. These include antacids, which come in the form of liquids or chewy tablets and reduce the acidity of the stomach contents.
Alginate products might also help. These make a foamy gel at the top of the stomach, providing a barrier to its acidic contents.
Doctors might prescribe stronger medications, such as lansoprazole, to people with persistent symptoms.
Laparoscopic Nissen fundoplication has a very good success rate.
In rare cases, a person with a hiatal hernia may require surgery under general anesthesia.
People who develop severe and long-term reflux problems may need to consider having an operation if lifestyle changes and drug treatments are not effective. Surgery also becomes necessary if a hernia is large enough to disrupt the blood supply.
The operations for hiatal hernias are laparoscopic. Surgeons perform these procedures through small "keyhole" cuts, so they are less invasive than surgery that requires a large incision.
A laparoscopic Nissen fundoplication (LNF) is one of the standard procedures for treating sliding hiatal hernias.
The operation lasts for up to 90 minutes and aims to pull the stomach back into place while tightening the diaphragm around the food pipe to prevent further bulging in the hernia.
According to the Cleveland Clinic, a person might experience up to a 90 percent improvement in their symptoms after an LNF.
A hiatal hernia occurs when the stomach pushes through the narrowest part of the diaphragm.
It rarely causes symptoms, but some people may experience acid reflux and heartburn. Adjusting the diet and taking antacids or alginate products can usually help reduce discomfort.
Obesity and older age contribute to the risk of a hiatal hernia, but the exact cause is not clear. Many risk factors for a hiatal hernia, such as genetics, are not preventable.
In severe cases, which are rare, surgery can help resolve a hiatal hernia. Some procedures, such as LNF, are highly effective, and people have an excellent outlook afterward.
Are other types of hernia more dangerous than hiatal hernias?
Other types of hernia, such as inguinal and femoral hernias, are much more dangerous than hiatal hernias due to the possibility of the abdominal organs becoming trapped in the weak muscle wall.
If this occurs, emergency surgery is necessary.Saurabh (Seth) Sethi, MD MPH Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.