Hiatus hernia

Next review due October 2023

A hiatus hernia is when part of your stomach slides upwards into your chest, which can cause symptoms such as heartburn.You don’t necessarily need any treatment for a hiatus hernia, but if it’s causing any problems there are lots of things that can help.

How a sliding hiatus hernia forms

About hiatus hernia

Usually, your stomach sits completely below a sheet of muscle, called your diaphragm.This separates your chest from your abdomen (tummy).There’s an opening in your diaphragm called a hiatus. Your oesophagus (the tube that carried food from your mouth to your stomach) passes through the hiatus. A hiatus hernia usually develops when part of your stomach slides up through this opening and into your chest.

A hiatus hernia doesn’t always cause problems. But it may allow acid from your stomach to travel the wrong way, back up your oesophagus.This is called gastro-oesophageal reflux disease (GORD), or acid reflux, and this is what causes your symptoms.

Types of hiatus hernia

There are two main types of hiatus hernia.

• Sliding hiatus hernia. This is when the join between your oesophagus and your stomach (the gastro-oesophageal junction) slides up into your chest, followed by the top part of your stomach. Around nine in 10 people with a hiatus hernia have this type.
• Rolling hiatus hernia (also called a para-oesophageal hiatus hernia). In this type, a part of your stomach passes up into your chest to lie alongside your oesophagus. Your gastro-oesophageal junction stays where it should be, below your diaphragm.

You can also have a mixed hiatus hernia, which is a combination of these types.These can become very large and include a lot of your stomach.You’re more likely to need surgery for this type.

Who gets a hiatus hernia?

Hiatus hernias are very common. Up to half of the population may have one, although it’s hard to say for sure, as many people don’t have symptoms.There are certain factors that make you more likely to develop a hiatus hernia. These include:

• being obese (very overweight) – this increases the pressure in your abdomen, which can lead to your stomach pushing against the opening in your diaphragm
• anything else that increases pressure in your abdomen, such as pregnancy or having a long-term cough
• getting older – this might be because some of the tissues in your diaphragm get weaker as you get older
• previous surgery or injury to your abdomen or oesophagus

Symptoms of hiatus hernia

Many people with a hiatus hernia don’t have any symptoms.

But, if you have a sliding hiatus hernia, you may develop gastro-oesophageal reflux disease (GORD). This is when acid from your stomach travels back up your oesophagus. Symptoms of GORD can include:

• heartburn – a burning sensation in your chest especially when you bend or lie down
• reflux of stomach acid into your mouth, especially when you’re lying down – this will taste sour
• feeling or being sick
• feeling bloated, or getting full quickly
• a night-time cough or wheeze
• pain in your chest or upper abdomen (tummy)
• finding it difficult or painful to swallow

You may notice certain things cause a flare-up of your symptoms, such as particular foods, drinking alcohol or feeling stressed. See the self-help section below for more information.

You can usually manage symptoms like these yourself, without needing to see a doctor. But if your symptoms don’t go away with over-the-counter medicines and lifestyle changes, or your symptoms are severe or getting worse, see your doctor. 

You should also see your doctor urgently if you’re having difficulty swallowing, or food gets stuck.

Diagnosis of hiatus hernia

If you see your doctor, they’ll ask about your symptoms, how they affect you and what could be triggering them. They may also ask about your family history, and examine you too. Your doctor can let you know things you can try to help improve your symptoms, without the need for tests.

If these measures haven’t worked or your doctor has any concerns about your symptoms, they may refer you to a gastroenterologist for further investigation and assessment.A gastroenterologist is a doctor who specialises in conditions of the digestive system. Your gastroenterologist may recommend you have some of the following tests.

• An endoscopy (also called a gastroscopy). In this test, a tube with a camera on the end (an endoscope) is passed through your mouth (or sometimes your nose) and down into your stomach.This produces pictures of the inside of your oesophagus and stomach on a screen, which your doctor can see. They can also take a biopsy (a tissue sample) at the same time.
• Barium swallow and meal. In this test, you swallow a substance that helps to show the outline of your oesophagus and stomach on an X-ray.
• Oesophageal functional tests. These measure how well your oesophagus is working, how much reflux you have, and if your symptoms are caused by reflux. The test involves passing a fine tube (catheter) into your nose and down into your oesophagus.
• Chest X-ray.This is one of the simplest tests your doctor may recommend.

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Self-help for hiatus hernia symptoms

There’s a lot you can do yourself to ease the symptoms of a hiatus hernia, and to help stop them from happening again.

• Try to lose any excess weight you may have. Obesity is strongly linked to hiatus hernia.
• Avoid large meals. Instead of eating three big meals, aim for several smaller ones throughout the day.
• Raise the head of your bed if heartburn bothers you at night, and don’t eat anything for several hours before you go to bed.
• Try to avoid things that raise the pressure inside your abdomen (tummy).This might include wearing tight clothing around your middle, such as tight belts, and weight training.
• If you notice that some foods and drinks make your heartburn worse, try cutting them out.Download our food and symptoms diary below, and for more information, see our FAQ: Which foods should I avoid with a hiatus hernia? below.
• If you smoke, try to stop, as smoking may trigger symptoms.
• If you drink alcohol, try to cut down and stick to recommended limits (no more than 14 units a week), as alcohol can also be a trigger.

Try printing and filling out the food and symptoms diary below to help you identify foods that cause you problems.

Treatment of hiatus hernia

Treatment for hiatus hernia depends on how severe your symptoms are and how much they’re bothering you. You won’t usually need treatment for a hiatus hernia at all if it’s not causing you any problems.

If you do get symptoms, making changes to your lifestyle and taking medicines can help to ease them, but they won’t cure your hiatus hernia.

Medicines

There are lots of indigestion medicines that can ease the symptoms of heartburn when they happen. You can buy many of these without a prescription, but some need to be prescribed by a doctor. Ask your pharmacist for advice if you need it.

Medicines which may be used to treat the symptoms of a hiatus hernia include the following:

• Antacids and/or alginates – you can buy these over-the-counter to help with indigestion, whenever you get symptoms.They work by neutralising the acid produced in your stomach, or forming a barrier over it. You may find them useful to take whenever your symptoms flare up, but you shouldn’t keep taking them for a long time.
• Proton pump inhibitors (PPIs) – these work by reducing the amount of acid your stomach produces.Your doctor may prescribe a PPI if you have ongoing symptoms of indigestion, or confirmed hiatus hernia. You may be offered the treatment for four to eight weeks at first.

Surgery

If medicines aren’t controlling your symptoms, they’re causing side-effects or you don’t want to carry on taking them long term, speak to your doctor. They may suggest you see a specialist surgeon to consider an operation.

If you have a rolling or a mixed hiatus hernia and have pain or vomiting after eating, then your doctor should also refer you to a specialist surgeon to consider an operation.

The most common surgical treatment for a hiatus hernia is an operation called a fundoplication.This is often done as a keyhole (laparoscopic) procedure, but sometimes you may need open surgery. It involves repairing your hiatus hernia and wrapping the top part of your stomach around your lower oesophagus (the tube that carries food from your mouth to your stomach). This can help to control your symptoms as well as reduce your hiatus hernia.

Complications of hiatus hernia

Occasionally, a hiatus hernia can lead to more serious problems.

Occasionally, if your hiatus hernia keeps letting stomach acid come up into your oesophagus, it can lead to more serious complications. These include the following.

• Inflammation of your oesophagus (oesophagitis). Your oesophagus can become damaged by the acid from your stomach, and this can lead to ulcers which may bleed.
• Anaemia caused by bleeding from an ulcer.
• Narrowed oesophagus (a stricture) – this is caused by scarring of your oesophagus from repeated inflammation.This can cause food to get stuck or to come back up.
• Barrett’s oesophagus. This is where the cells that line your oesophagus get damaged and become abnormal.Eventually, these cells may become cancerous.If you have Barrett’s oesophagus, your doctor may suggest monitoring cells in your oesophagus to spot and then treat any changes quickly.

If you have a rolling hernia, the part of your stomach which has gone up into your chest can become trapped by the diaphragm, cutting off the blood supply. This is called a strangulated hernia and causes severe pain.If this happens, it is an emergency and you’ll need an operation immediately.