Hiatus Hernia

What is a hiatus hernia?

A hiatus hernia occurs when a portion of the stomach moves upwards through an opening in the diaphragm and into the chest cavity. The diaphragm is a large sheet muscle that separates the chest from the abdomen and plays an important role in breathing. It contains a small natural opening called the oesophageal hiatus, through which the oesophagus passes before joining the stomach.

Under normal circumstances, the stomach sits entirely below the diaphragm. In a hiatus hernia, the tissues supporting the lower oesophagus and upper stomach become weakened or stretched. This allows part of the stomach to slide or push through the hiatus into the chest. The degree of herniation can vary, ranging from small and incidental findings to larger defects that may cause significant symptoms.

Because the lower oesophageal sphincter is located near this junction, displacement of the stomach can interfere with its normal function. The sphincter closes off the entrance to the stomach and prevents acid reflux from occurring. This is why hiatus hernia is often associated with acid reflux and related symptoms. Early assessment helps determine whether the condition is mild and manageable with medication or whether further intervention is required.

What are the different types of hiatus hernia?

Hiatus hernias are classified based on how the stomach moves through the diaphragm and the position of the gastro-oesophageal junction. The type of hernia influences both symptoms and management decisions.

What causes a hiatus hernia?

A hiatus hernia develops when the structures that normally keep the stomach below the diaphragm become weakened or stretched. Several factors can contribute to this change over time.

• Age-related weakening of the diaphragm — the tissues around the oesophageal hiatus may lose strength and elasticity with age, increasing the likelihood of herniation.

• Increased abdominal pressure — conditions that raise pressure within the abdomen, such as obesity, pregnancy, chronic coughing or persistent straining, can push part of the stomach upwards through the hiatus.

• Heavy lifting — repeated lifting of heavy objects can place strain on the diaphragm and abdominal wall, contributing to gradual weakening.

• Previous surgery or trauma — surgical procedures involving the upper abdomen or chest may alter normal anatomy and predispose to hernia formation.

• Congenital weakness — some individuals are born with a larger or inherently weaker hiatus, which increases susceptibility to herniation later in life.

What are the symptoms of a hiatus hernia?

Many hiatus hernias cause mild or no symptoms, particularly smaller sliding types. When symptoms do occur, they are often related to acid reflux.

• Heartburn — a burning sensation behind the breastbone, often worse after meals or when lying down.

• Acid reflux — the backflow of stomach contents into the oesophagus, leading to irritation and discomfort.

• Regurgitation — a sensation of food or sour fluid rising into the throat or mouth.

• Chest discomfort — a feeling of pressure or pain in the chest that may mimic cardiac symptoms.

• Difficulty swallowing — larger hernias or associated inflammation may cause a sensation of food sticking.

• Bloating or early fullness — some individuals report upper abdominal fullness or discomfort after eating.

• Silent cases — in some patients, a hiatus hernia is discovered incidentally during investigations for unrelated symptoms and causes no noticeable problems.

Persistent or worsening symptoms warrant medical evaluation to determine the extent of the hernia and guide appropriate management.

How is hiatus hernia linked to acid reflux (GORD)?

Hiatus hernia is closely associated with gastro-oesophageal reflux disease (GORD) because it can interfere with the normal function of the lower oesophageal sphincter (LOS). The LOS is a ring of muscle located at the junction between the oesophagus and the stomach. Its role is to prevent stomach contents from flowing back into the oesophagus.

When part of the stomach moves above the diaphragm, the normal pressure relationship between the chest and abdomen changes. This displacement can weaken the lower oesophageal sphincter or alter its position, reducing its ability to remain tightly closed. As a result, acid and stomach contents are more likely to reflux into the oesophagus.

Because both conditions involve acid exposure to the oesophagus, the symptoms often overlap. Patients may experience heartburn, regurgitation, chest discomfort or chronic throat irritation. While not everyone with a hiatus hernia develops reflux, the presence of a hernia increases the likelihood and severity of GORD symptoms.

How is a hiatus hernia diagnosed?

Diagnosis begins with a clinical evaluation based on symptoms and risk factors. Many hiatus hernias are discovered during investigation for reflux or upper abdominal discomfort.

• Clinical assessment — a detailed history helps identify typical reflux symptoms, swallowing difficulties or complications that may require further testing.

• Upper gastrointestinal endoscopy — endoscopy allows direct visualisation of the oesophagus and stomach. It can confirm the presence of a hiatus hernia, assess for inflammation, and exclude other conditions such as ulcers or Barrett’s oesophagus.

• Barium swallow study — this imaging test involves swallowing contrast material while X-rays are taken. It can demonstrate the size and type of hernia, particularly in cases where anatomy needs further clarification.

• CT scan — in larger or para-oesophageal hernias, cross-sectional imaging may be used to evaluate the extent of herniation and assess for complications.

What complications can occur with a hiatus hernia?

While many hiatus hernias are mild, some can lead to complications if left untreated.

• Chronic reflux — persistent acid exposure may lead to ongoing discomfort and damage to the oesophageal lining.

• Oesophagitis — inflammation of the oesophagus can develop due to repeated acid irritation.

• Strangulation — in para-oesophageal hernias, part of the stomach may become trapped and lose its blood supply, which is a surgical emergency.

• Anaemia — chronic irritation or small areas of bleeding from the herniated stomach lining may lead to iron-deficiency anaemia.

• Aspiration — severe reflux may allow stomach contents to enter the airway, potentially causing cough, wheeze or recurrent chest infections.

Early recognition and appropriate management significantly reduce the likelihood of these complications.

When does a hiatus hernia require treatment?

Treatment is usually considered in the following situations:

• Persistent or troublesome symptoms — ongoing heartburn, regurgitation, chest discomfort or swallowing difficulties that affect daily life despite medication.

• Poor response to medical therapy — reflux symptoms that remain uncontrolled despite adequate acid suppression treatment.

• Large para-oesophageal hernia — hernias that carry a higher risk of obstruction or strangulation may require closer monitoring or surgical assessment.

• Development of complications — evidence of oesophagitis, bleeding, iron-deficiency anaemia or recurrent aspiration.

• Progressive or worsening symptoms — increasing pain, difficulty swallowing or signs suggestive of compromised blood supply to the stomach.

Management is individualised, with mild cases treated conservatively and higher-risk cases evaluated for surgical repair when appropriate.

What are the treatment options for hiatus hernia?

Treatment for hiatus hernia aims to relieve symptoms, control reflux, and prevent complications. The choice of treatment depends on the type of hernia and the severity of symptoms.

• Lifestyle modifications — weight management, avoiding large meals, reducing late-night eating, elevating the head of the bed and limiting foods that trigger reflux can significantly improve symptoms.

• Acid suppression therapy — proton pump inhibitors (PPIs) or other acid-reducing medications help control reflux symptoms and protect the oesophagus from acid-related injury.

• Surgical repair — in selected cases, particularly with large para-oesophageal hernias or reflux not controlled by medication, laparoscopic repair may be recommended. This procedure restores the stomach to its normal position and may include fundoplication, which reinforces the lower oesophageal sphincter to reduce reflux.

Surgery is generally considered when symptoms remain severe despite optimal medical therapy, when complications arise or when there is a significant risk of strangulation.

Can a hiatus hernia go away on its own?

No, the structural defect itself doesn't resolve without intervention. Once the tissues around the hiatus have weakened or stretched enough for the stomach to herniate through, they do not tighten back up on their own.

What can improve without treatment are the symptoms. Particularly in small sliding hernias, lifestyle changes like weight loss, dietary adjustments and elevating the head of the bed can significantly reduce reflux and discomfort. However, the hernia itself remains.

Summary

A hiatus hernia occurs when part of the stomach moves through the diaphragm into the chest cavity. While many cases are mild and discovered incidentally, some can cause significant reflux symptoms or lead to complications. The condition is closely linked to gastro-oesophageal reflux due to disruption of the lower oesophageal sphincter. 

Diagnosis is typically confirmed through endoscopy or imaging, and management ranges from lifestyle modification and medication to surgical repair in selected cases. Early assessment ensures that symptoms are properly evaluated and that higher-risk hernias are identified promptly.

If you are experiencing persistent reflux, difficulty swallowing, chest discomfort or unexplained anaemia, schedule a consultation with Dr. Aaron Poh at Alpine Surgical Practice for a comprehensive evaluation and personalised management plan.

Frequently Asked Questions (FAQs)