Hiatal Hernia: Signs, Symptoms, and Complications

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Robert Burakoff, MD, MPH, is board-certified in gastroentrology. He is the vice chair for ambulatory services for the department of medicine at Weill Cornell Medical College in New York.

A hiatal hernia, also known as a stomach hernia, most often affects people over 50. As many as 90% of people who have a stomach hernia will not experience symptoms. Among those who do, heartburn, abdominal discomfort, throat irritation, belching, and regurgitation are common. While symptoms like these can be aggravating, they are usually not serious. Rarely, severe complications can develop, requiring emergency treatment.

Generally speaking, small herniation of the stomach is not inherently harmful and is unlikely to cause any direct pain or discomfort. A hiatal hernia can alter the structures and mechanisms that keep food and acids where they belong.

The key to this problem is a structure called the lower esophageal sphincter (LES). When a hiatal herniation occurs, it can change the position of this muscular valve, allowing the contents of the stomach to backflow into the esophagus (known as reflux).

Related, intermittent symptoms can include:

Generally speaking, it is only when a hernia gets larger that it can manifest in this way. If the LES weakens even further, which can happen with age, related symptoms can get progressively worse.

People with a hiatal hernia are more likely to develop gastroesophageal reflux disease (GERD), a chronic form of reflux that can interfere with quality of life. The persistence of GERD symptoms can lead to a chronic cough, chest pain, asthma, and progressive damage to your tooth enamel.

Broadly speaking, there are two types of hiatal hernia: a sliding hiatal hernia and a paraesophageal hernia. While a sliding hernia is the most common, accounting for around 95% of all diagnoses, a paraesophageal hernia is potentially more serious.

Unlike a sliding hernia, a paraesophageal hernia doesn't readily slide in and out of the hiatus. Rather, it can get progressively larger and slip even further into the chest cavity as time goes by. It is at this later stage that the complications can become serious and, in rare cases, life-threatening.

Complications may include esophageal compression, gastric obstruction, strangulation, and an extremely rare condition known as an intrathoracic stomach.

Compression of the esophagus can occur as the hernia presses against the esophageal wall. When this happens, food can get stuck in the esophagus, causing chest pain after eating and difficulty swallowing (dysphagia).

While esophageal compression is not considered a medical emergency, it may require medications to alleviate or prevent worsening symptoms.

Incarceration occurs when the herniated portion of the stomach becomes trapped in the hiatus. In some cases, the symptoms of incarceration may be chronic but minimal (mostly a sensation of chest pressure as food passes through the upper digestive tract). But, it can cause obstruction or impede blood circulation.

Incarceration itself is not a medical emergency unless a severe obstruction occurs.

Volvulus is when a herniated stomach twists more than 180 degrees, causing a severe gastric obstruction. While it can occur with hiatal hernia, it can also occur without it and is very uncommon. Symptoms may include dysphagia, chest pain after eating, belching, and vomiting.

If this problem progresses, it can cause upper abdominal pain and distention, vomiting leading to nonproductive retching, and gastric bleeding (due to the abnormally increased blood pressure).

Acute symptomatic volvulus generally occurs in people over age 50 and is considered a medical emergency with a 30 to 50% risk of mortality.

Strangulation is a cut-off of the blood supply to the stomach, either due to volvulus or incarceration. Symptoms include a sudden, sharp chest pain; fever; fatigue; bloating; vomiting; an inability to pass gas; constipation; warmth or redness over the herniation; rapid heart rate; and bloody or tarry stools (due to gastrointestinal bleeding).

This is considered a medical emergency as the blockage can result in rapid organ damage. If not treated immediately, strangulation can lead to gangrene, shock, and death.

An intrathoracic stomach is a rare condition in which the stomach slips entirely into the chest cavity. Not all cases cause symptoms, but the most common signs are dyspnea (shortness of breath) and a feeling of chest fullness and pressure. Other symptoms can include vomiting, retching, dysphagia, gastrointestinal bleeding, and aspiration pneumonia (caused when food is coughed up into the lungs).

The enlarged hiatal gap can cause other organs to slip into the chest cavity, including the pancreas, liver, or colon. Surgery is the only means to correct this rare but serious complication.

The vast majority of hiatal hernias can be easily managed with over-the-counter medications, weight loss, and an adjustment to your diet. Hiatal hernias generally do not need to be medically managed unless the symptoms are persistent or worsening.

With that being said, you should see a doctor if your symptoms don't improve despite conservative management. In some cases, adjusting your prescription drugs and other interventions may be needed.

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You should seek immediate medical care if reflux symptoms are accompanied by high fever (over 100.4 degrees), severe chest pain, rapid heart rate, non-productive retching, or bloody stools. These may be the signs of a severe and potentially life-threatening hernial complication.

You are likely to feel severe chest pain if you have a strangulated hiatal hernia. Heart palpitations and shortness of breath are also common. Other sensations can include nausea, difficulty swallowing, and bloating. These are signs of a medical emergency; if you experience these symptoms, you should seek medical help right away.

Hiatal hernias do not flare up. It is a structural problem. But symptoms can be worsened by eating foods that trigger gastroesophageal reflux (GERD), eating large meals, lying down after eating, and stress.

If you have a hiatal hernia, avoid food that is fatty, oily, highly acidic, or processed. Also avoid citrus fruits such as oranges or limes, which can cause irritation.

No, only a trained medical professional can perform surgery to remove a hiatal hernia. Thankfully, a majority of people with a hiatal hernia are able to manage their symptoms using over-the-counter medication, diet changes, and weight loss. Surgery usually isn't required unless symptoms are persistent or become worse.

A hiatal hernia may cause heartburn and abdominal discomfort. That said, up to 90% of people with a hiatal hernia won't experience symptoms. Emergency treatment is rarely needed.

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