Hiatal Hernia

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A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm and into the chest cavity. The diaphragm is the thin muscle wall that separates the chest cavity from the abdomen. The opening in the diaphragm is where the esophagus and stomach join.

A hiatal hernia can develop in people of all ages and both sexes, although it frequently occurs in people age 50 and older. Hiatal hernia occurs more often in overweight people and smokers.

The most common cause of a hiatal hernia is an increase in pressure in the abdominal cavity. Your abdominal cavity is the space in the middle of your body that holds several organs, including the:

This pressure can build up from things like:

There are also other reasons a hiatal hernia could develop. You may experience a hiatal hernia during pregnancy, if you are obese, or if there’s extra fluid in your abdomen.

Increased pressure in the abdomen (arrows) causes part of the stomach to push through the diaphragm and into the chest cavity.

Many people with a hiatal hernia never have symptoms. Some people with hiatal hernia have some of the same symptoms as gastroesophageal reflex disease (GERD). GERD occurs when digestive juices move from the stomach back into the esophagus. Symptoms of GERD include:

Although there appears to be a link between hiatal hernia and GERD, one condition does not seem to cause the other. Many people have a hiatal hernia without having GERD, and others have GERD without having a hiatal hernia.

Another symptom of a hiatal hernia is chest pain. Since chest pain can also be a symptom of a heart attack, it’s important to contact your healthcare provider or go to the emergency room if you experience any chest pain.

Several tests can be done to help diagnose a hiatal hernia. These include a barium swallow test, an endoscopy procedure, esophageal manometric studies, a pH test and gastric emptying studies.

Most hiatal hernias do not cause problems and rarely need treatment. However, since some patients with a hiatal hernia have symptoms of GERD, treatment starts with methods used to manage GERD. These include making such lifestyle changes as:

Sometimes, a medication called a proton-pump inhibitor might be used to treat hiatal hernia. This medication is another way to decrease the amount of stomach acid you have, which can help prevent reflux. When you take this medication, your body doesn’t make as much stomach acid as normal. This is similar to H-blocker medications.

In many cases, over-the-counter medications can help you with some symptoms of hiatal hernia. Antacids are the most common medication you might use for relief. However, if you take over-the-counter medications for longer than two weeks without any improvement, see your healthcare provider. Prescription medications are typically the next step. These can include:

If the portion of the stomach entering the esophagus is being squeezed so tightly that the blood supply is being cut off, you’ll need to have surgery. Surgery may also be needed in people with a hiatal hernia who have severe, long-lasting (chronic) esophageal reflux whose symptoms are not relieved by medical treatments. The goal of this surgery is to correct gastroesophageal reflux by creating an improved valve mechanism at the bottom of the esophagus. Think of this valve as a swinging door. It opens to let food pass down into the stomach and then closes to keep stomach contents from going back up the esophagus. When this valve doesn’t work correctly, your stomach contents can go the wrong way and damage your esophagus. If left untreated, chronic gastroesophageal reflux can cause complications such as esophagitis (inflammation), esophageal ulcers, bleeding or scarring of the esophagus.

Surgery for repairing a hiatal hernia involves:

During surgery, your surgeon will wrap the upper part of the stomach (called the fundus) around the lower portion of the esophagus. This creates a permanently tight sphincter (the valve) so that stomach contents will not move back (reflux) into the esophagus.

Called a fundoplication, there are two versions of this surgery. An open fundoplication surgery involves a larger incision. This type of procedure may need to be done in some very severe cases and it allows for greater visibility during surgery. However, open surgeries require a longer recovery time in the hospital. In many cases, the surgeon will decide to use a laparoscopic approach instead.

A laparoscopic surgery is done through several small incisions instead of one big cut. This is considered a minimally invasive option. The specific laparoscopic procedure used to repair a hiatal hernia is called the Nissen fundoplication. This procedure creates a permanent solution to your hiatal hernia symptoms. During the procedure, your surgeon will make five or six tiny incisions in the abdomen. The laparoscope (a tool that allows the surgical team to see your internal organs on a screen in the operating room) and other surgical instruments are inserted through the small incisions. The fundus is wrapped around the esophagus and the sphincter is tightened during surgery. The advantages of laparoscopic surgery compared to an open surgery include:

A laparoscopic repair of hiatal hernia and reflux, called Nissen Fundoplication, is very effective in most patients. This surgery requires general anesthesia and a short stay in the hospital. If you need to have an open surgical procedure, the recovery time will be longer and you may need to stay in the hospital for several days. After surgery, most patients no longer require long-term treatment with prescription or over-the-counter antacid medications.

Last reviewed by a Cleveland Clinic medical professional on 01/09/2020.

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