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Hiatus Hernia

A hiatus hernia is when part of the stomach moves through a hiatus (a small opening) in the diaphragm into the chest. Hiatus hernias are common in people over 50. Often they don't cause any problems, but they can cause pain and heartburn.

About hiatus hernia 

Normally, your stomach is completely below your diaphragm – the muscular sheet that separates your abdomen (tummy) from your chest cavity.

The weakest part of your diaphragm is the opening that your oesophagus (the pipe that goes from your mouth to your stomach) passes through. A hiatus hernia forms when part of your stomach protrudes through this opening and into your chest cavity.

Types of hiatus hernia 

Sliding hiatus hernia

This is the most common type, affecting 80 percent of people with a hiatus hernia. It occurs when the top part of your stomach, called the gastro-oesophageal sphincter, slides up through your diaphragm.

Hiayus Hernia Sliding

How a sliding hiatus hernia forms

Rolling hiatus hernia

This type affects only about 20 percent of people with a hiatus hernia. It involves part of your stomach bulging up through the opening in your diaphragm, while your gastro-oesophageal sphincter stays below it. It's sometimes called a para-oesophageal hernia.

Hiatus hernia sliding

How a rolling hiatus hernia forms

Symptoms of hiatus hernia 

Often, a hiatus hernia won't cause any symptoms. However, it may cause a feeling of warmth or burning in your chest, which is called heartburn. This happens when the contents of your stomach, which are acidic, reflux (flow backwards) into your oesophagus. If you have heartburn symptoms that go on for a long time or are severe, this is called gastro-oesophageal reflux disease (GORD).Other symptoms include:

  • severe pain or discomfort in your chest
  • belching
  • hiccups
  • gurgling noises in your chest.

Some people develop a croaky voice or asthma symptoms.

Your symptoms may start or get worse after eating, while lying down or when you bend forward.

Complications of hiatus hernia 

Occasionally, a hiatus hernia can lead to more serious problems. Acid from your stomach contents can sometimes cause damage to the lower end of your oesophagus. This damage is made more likely by a hiatus hernia and can lead to ulcers (breaks in the lining of your oesophagus). If your ulcers bleed, you may vomit blood. Seek urgent medical attention if you see blood in your vomit.

A bleeding ulcer can also lead to anaemia, a condition where you have too few red blood cells or not enough oxygen-carrying haemoglobin in your blood. In the long term, when ulcers have healed they can cause narrowing of your oesophagus, which can make swallowing difficult and painful and cause you to regurgitate food.

The blood supply to your stomach can also be affected if a segment of your stomach gets tightly trapped in your chest area. This is known as a strangulated hernia. If you have a rolling hiatus hernia, your stomach can become blocked, leading to pain and vomiting.

Causes of hiatus hernia 

The exact reasons why you may develop hiatus hernia aren't fully understood at present. However, hernias tend to happen when the tough fibres that normally hold your gastro-oesophageal sphincter in place stretch. The muscles of your diaphragm may also become more flexible. Both of these probably occur as you get older. About one in three people over 50 have a small hiatus hernia, usually without any symptoms.

Anything that increases the pressure inside your abdomen can increase the size of a hernia. This includes the sharp, physical movements of coughing, vomiting and straining; being pregnant, or if you’re overweight or obese.

Diagnosis of hiatus hernia 

Your GP will ask about your symptoms and examine you. They may also ask about your medical history. You may be referred to a gastroenterologist – a doctor specialising in the digestive system – for tests, which may include the following:

  • Endoscopy. This allows a doctor to look inside the body using a narrow, flexible, tube-like telescopic camera called an endoscope. Your doctor will use it to look closely at any sore spots or ulcers and can take a sample of tissue (a biopsy), if needed.
  • X-ray with barium. This test involves swallowing a drink containing a substance called barium, a powdered metal that illuminates the digestive organs during X-rays. You may also be asked for a sample of blood to check for anaemia.

Treatment of hiatus hernia 

Self-help

You can help reduce your symptoms and prevent further problems by making positive lifestyle changes, such as:

  • maintaining a healthy weight, and making an effort to lose weight if you're overweight or obese
  • not smoking, as it increases the risks of reflux problems
  • eating small, frequent meals, rather than occasional large meals, and at least three hours before bedtime
  • eating a diet low in carbohydrate and fat
  • drinking less coffee and other caffeinated drinks, soft drinks and alcohol
  • wearing loose-fitting, comfortable clothes and avoiding tight belts
  • taking care not to bend over sharply, for example while doing abdominal exercises
  • sleeping with the head of your bed raised by about 20-30cm with something sturdy and solid
  • trying relaxation techniques such as meditation, yoga and deep breathing to help manage stress.

Medicines

Antacids work to reduce reflux symptoms by neutralising your stomach acid. They can be bought over-the-counter and are taken as either liquid or tablets that can be swallowed or chewed. If antacids don't work for you, or you need to take large quantities to relieve your symptoms, your doctor or pharmacist may recommend a different over-the-counter medicine such as a proton pump inhibitor or an H2 blocker.

Proton pump inhibitors stop acid production in your stomach and are effective in relieving symptoms. H2 blockers provide quick relief by reducing the amount of acid that your stomach produces, but they aren't as effective as proton pump inhibitors.

If you need to take medicines for indigestion regularly, for more than two or three times a week, your doctor may prescribe proton pump inhibitors or H2 blockers in higher doses to be used for a month. The doctor can then reassess whether you need to continue using this medication at this dose.

Another type of medicine you may be prescribed is a prokinetic or motility stimulant, which quickens the rate at which your stomach empties and helps stop your stomach contents refluxing (returning) into your oesophagus.

Surgery

A sliding hiatus hernia can cause severe symptoms or complications that may require surgery, but this is rare.

You're more likely to need surgery if you have a rolling hiatus hernia. Surgery involves pushing your stomach back into the correct position, securing it and tightening your diaphragm around the lower part of your oesophagus. This prevents acid reflux and heartburn.

The procedure is usually done as keyhole surgery using a laparoscope – a small thin tube containing a camera. The recovery time is quicker than for open surgery, which is done through a cut in your abdomen.

You’ll probably need to stay in hospital for two to three days and recovery usually takes one week. Side effects and complications are rare but can include:

  • pain when you swallow, which usually improves after one to three months
  • bloating from gas, especially after meals
  • difficulty burping, which gradually improves
  • infection and bruising
  • long-term pain.

It's also possible that the hernia will return.

The exact risks differ for every person, so we haven't included specific details here. Ask your surgeon to explain how these risks apply to you and about the general risks of surgery.

Further information 

Gastroenterological Society of Australia (GESA)
www.gesa.org.au/consumer.asp

Sources 

Clinical Knowledge Summaries. Dyspepsia – unidentified cause. [online] London: National Institutes for Health and Clinical Excellence. 2008 [last updated Jul 2009, accessed 6 Jul 2011] Available from: http://www.cks.nhs.uk/dyspepsia_unidentified_cause

Clinical Knowledge Summaries. Dyspepsia – proven GORD. [online] London: National Institutes for Health and Clinical Excellence. 2008 [last updated Jul 2009, accessed 6 Jul 2011] Available from: http://www.cks.nhs.uk/dyspepsia_proven_gord

Festi D Scaioli E Baldi F et al. Body weight, lifestyle, dietary habits and gastro oesophageal reflux disease. World J Gastroenterol. 2009; 15(14): 1690-1701.

Kaltenbach T Crockett S Gerson LB. Are Lifestyle Measures Effective in Patients with Gastroesophageal Reflux Disease? An Evidence-Based Approach. Arch Intern Med. 2006; 166: 965–971.

Moayyedi P Talley NJ. Gastro-oesophageal reflux disease. Lancet. 2006; 367:2086-2100.

myDr. Hiatus hernia: what is it?. [online] St Leonards, NSW: UBM Medica Australia. c2000-2011 [Last reviewed Jun 2009, accessed 6 Jul 2011] Available from: http://www.mydr.com.au/gastrointestinal-health/hiatus-hernia-what-is-it

National Institute for Health and Clinical Excellence (NICE). Dyspepsia: managing dyspepsia in adults in primary care. [online] Aug 2004 [accessed 6 Jul 2011] Available from: http://guidance.nice.org.uk/CG17

Personal communication, Martin Kurzer, surgeon and secretary of the British Hernia Society, 35-43 Lincoln's Inn Fields, London WC2A 3PE, 16 September 2009

Rossi S (ed). Australian Medicines Handbook. Adelaide: Australian Medicines Handbook. 2009.

Simon C, Everitt H, Kendrick T. Oxford Handbook of General Practice. 2nd ed. Oxford: Oxford University Press, 2006: 436-37

Stanghellini V. Relationship between upper gastrointestinal symptoms and lifestyle, psychosocial factors and comorbidity in the general population: results from the Domestic/International Gastroenterology Surveillance Study (DIGEST). Scand J Gastroenterol. 1999; Suppl 231: 29–37.

Last published: 30 July 2011

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