A hiatus hernia, or hiatal hernia, is when part of the stomach squeezes into the chest through an opening in the diaphragm called the hiatus.
The diaphragm is a large, thin sheet of muscle located between the chest and the abdomen (tummy).
Hiatus hernia and heartburn
A hiatus hernia itself rarely has any noticeable symptoms. However, it can cause a problem called gastro-oesophageal reflux disease (GORD).
GORD is when stomach acid leaks into the oesophagus (the tube that carries food to the stomach). It can occur if a hiatus hernia prevents the valve at the bottom of the oesophagus from working properly.
Your oesophagus can become severely irritated because it is not protected against stomach acid. This may result in symptoms such as heartburn, chest pain, an unpleasant sour taste in your mouth, and problems swallowing (dysphagia).
You should see your GP if you have frequent and severe symptoms of GORD.
Who is affected?
Hiatus hernia can affect anyone, but it's more common in women and people who are over 50, overweight, pregnant or who smoke. It's estimated that a third of people over 50 have a hiatus hernia.
There's also a rare type of hiatus hernia that affects newborn babies.
Why it happens
It's not exactly clear what causes hiatus hernia, but it may be the result of the diaphragm becoming weak with age or pressure on the abdomen.
Hiatus hernia can occur in newborn babies if the stomach or diaphragm doesn't develop properly.
Types of hiatus hernia
There are two main types of hiatus hernia:
sliding hiatus hernias – hernias that move up and down, in and out of the chest area (more than 80% of hiatus hernias are this type)
para-oesophageal hiatus hernias – also called rolling hiatus hernias, this is where part of the stomach pushes up through the hole in the diaphragm next to the oesophagus (about 5-15% of hiatus hernias are this type)
This information mainly focuses on sliding hiatus hernias.
The type of hiatus hernia can usually be diagnosed using an X-ray or an endoscopy, where a long, tube-like instrument with a video camera and light source is used.
Treating hiatus hernia
Treatment for sliding hiatus hernia usually focuses on relieving the symptoms of GORD, such as heartburn.
Lifestyle changes and medication are the preferred treatments. Surgery is usually only recommended as an alternative to long-term medication or if other treatments haven't worked.
Lifestyle advice may include:
eating smaller, more frequent meals rather than three large meals a day
avoiding lying down (including going to bed) for three hours after eating or drinking
removing any foods or drinks that make your symptoms worse from your diet
If a hiatus hernia isn't causing any noticeable problems, it doesn't usually need to be treated.
Para-oesophageal hiatus hernias are repaired surgically if there is a risk of serious complications.
It's rare for a hiatus hernia to cause complications, but long-term damage to the oesophagus caused by leaking stomach acid can lead to ulcers, scarring and changes to the cells of the oesophagus, which can increase your risk of oesophageal cancer.
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Diagnosing a hiatus hernia
A hiatus hernia can usually be diagnosed after an endoscopy or an X-ray. Your GP will make an appointment for you to have this done in hospital.
During an endoscopy the inside of your body is directly examined using an endoscope (a long, thin flexible tube that has a light source and video camera at one end), which sends images to an external monitor.
The endoscope will be inserted into your mouth and down your throat to look for any problems. The procedure is usually done while you are awake and you may be given a sedative to help you to relax.
Barium meal X-ray
The barium meal X-ray, also called the barium swallow test, is one of the most effective ways of identifying a hiatus hernia.
As part of the test you will be asked to drink some barium solution. Barium is a non-toxic chemical that shows up clearly on an X-ray. Once the barium moves down into your digestive system a series of X-rays will be taken to identify any problems.
If you need to have a barium meal X-ray, you will not be able to eat or drink anything for at least six hours before the procedure so that your stomach and duodenum (top of the small intestine) are empty. You may be given an injection to relax the muscles in your digestive system.
You will be given a white, chalky liquid containing barium to drink while lying down. This means your specialist will be able to see your stomach on an X-ray monitor more easily, as well as any ulcers or abnormal growths. Your bed may be tipped slightly during the test so that the barium fills all the areas of your stomach.
A barium swallow usually takes about 15 minutes to perform. Afterwards you will be able to eat and drink as normal, although you may need to drink more water to help flush the barium out of your system.
You may feel slightly sick after a barium meal X-ray and the barium may cause constipation. Your stools may also be white for a few days afterwards as the barium passes through your system.
Treating a hiatus hernia
Treatment for a hiatus hernia is usually only necessary if it's causing problems.
In most cases, people with a hiatus hernia only experience problems if the hernia causes gastro-oesophageal reflux disease (GORD). GORD can cause symptoms such as heartburn and an unpleasant taste in your mouth.
Lifestyle changes and medication are the preferred treatments, although surgery may be used as an alternative to long-term medication or if other treatments are ineffective.
A number of self-care techniques may help relieve symptoms of GORD caused by a hiatus hernia. These include:
eating smaller, more frequent meals rather than three large meals a day
avoiding lying down (including going to bed) for at least three hours after eating or drinking
avoiding drinking during the night
removing certain foods from your diet if you think they make your symptoms worse
avoiding alcohol, caffeine, chocolate, tomatoes, fatty foods, spicy foods and acidic food or drinks (such as citrus fruit juice) if they make your symptoms worse
avoiding bending over or stooping, especially after eating or drinking
raising the head of your bed by around 20cm (8 inches) by placing a piece of wood or blocks under it – do not use extra pillows because this may increase pressure on your abdomen
If you are overweight, losing weight may help reduce the severity and frequency of your symptoms.
If you smoke, consider stopping. Tobacco smoke can irritate your digestive system and may make your symptoms worse.
A number of different medications can be used to treat symptoms of hiatus hernia. These are described below.
Antacid medicines can relieve some of the symptoms of hiatus hernia. They come in liquid or tablet form and can be swallowed or chewed. They help neutralise stomach acid when they reach the oesophagus and stomach by making it less acidic.
However, antacid medicines don't work for everyone. They're not a long-term solution if symptoms persist or you are in extreme discomfort.
Antacids should not be taken at the same time as other medicines because they can stop other medicines from being properly absorbed by your body. They may also damage the special coating on some types of tablets. Ask your GP or pharmacist for advice.
Alginates are an alternative medicine t antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.
In some cases, a medicine known as an H2-receptor antagonist (H2RA) may be recommended if a hiatus hernia is causing GORD. Examples of H2RAs include cimetidine, famotidine and ranitidine.
H2RAs block the effects of the chemical histamine, which your body uses to produce stomach acid. H2RAs therefore help reduce the amount of acid in your stomach.
Side effects of H2RAs are uncommon. However, possible side effects may include diarrhoea, headaches, tiredness and a rash.
Some H2RAs are available over the counter at pharmacies. These types of HR2As are taken in a lower dosage than the ones available on prescription. Ask your GP or pharmacist if you are not sure whether these medicines are suitable for you.
Proton-pump inhibitors (PPIs)
Your GP may prescribe a medication called a proton-pump inhibitor (PPI). PPIs work by reducing the amount of acid produced by your stomach. Examples of the PPIs you may be prescribed includeomeprazole, lansoprazole, rabeprazole and esomeprazole.
Most people tolerate PPI well and side effects are uncommon. When they do occur they are usually mild and may include headaches, diarrhoea, feeling sick, or constipation.
To minimise any side effects, your GP will prescribe the lowest possible dose of PPIs they think will be effective. You should let your GP know if the prescribed dose of PPIs doesn't work. A stronger dose may be needed.
If your symptoms are not responding to other forms of treatment, your GP may prescribe a short-term dose of a prokinetic. Examples of prokinetic medicines include domperidone and metoclopramide.
Prokinetics speed up the emptying of your stomach, which means there is less opportunity for acid to irritate your oesophagus.
A small number of people who take prokinetics have what is known as extrapyramidal symptoms. Extrapyramidal symptoms are a series of related side effects that affect your nervous system and can include:
problems opening your mouth fully
a tendency to stick your tongue out of your mouth
abnormal changes in body posture
If you have the above symptoms while taking prokinetics, stop taking them and contact your GP or out-of-hours doctor immediately. They may recommend you stop taking them. The symptoms should stop within 24 hours of the medicine being withdrawn.
Prokinetics are not usually recommended for people under the age of 20 because of an increased risk of extrapyramidal symptoms.
Surgery is usually only recommended for a sliding hiatus hernia if the problem fails to respond to lifestyle changes and medication.
You may also wish to consider surgery if you have persistent and troublesome symptoms but do not want to take medication on a long-term basis.
Prior to surgery you may need further investigations to check how well the oesophagus moves (manometry) and how much acid is being refluxed (24-hour oesopageal pH studies).
Laparoscopic nissen fundoplication (LNF)
A procedure called a laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques used to treat GORD and sliding hiatus hernias.
LNF is a type of keyhole surgery that involves making a series of small cuts in your abdomen. Carbon dioxide gas is used to inflate your abdomen to give the surgeon room to work in.
During LNF, the stomach is put back into the correct position and the diaphragm around the lower part of the oesophagus is tightened. This should prevent any acid moving back out of your stomach.
LNF is carried out under general anaesthetic, so you will not feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.
After having LNF, most people can leave hospital once they have recovered from the effects of the general anaesthetic. This is usually within two to three days. Depending on the type of job you do, you should be able to return to work within three to six weeks.
For the first six weeks after surgery it is recommended you only eat soft food, such as mince, mashed potatoes or soup. Avoid eating hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.
Common side effects of LNF include difficulties swallowing (dysphagia), belching, bloating and flatulence.
These side effects should resolve over the course of a few months. However, in about 1 in 100 cases they can be persistent. In such circumstances, further corrective surgery may be required.
Para-oesophageal hiatus hernia
If you have a para-oesophageal hiatus hernia, where the stomach pushes up through the hole in the diaphragm next to the oesophagus, surgery may be recommended to reduce the risk of the hernia becoming strangulated..
Complications of a hiatus hernia
Complications from a hiatus hernia are rare, but they can be serious.
Hiatus hernias that slide in and out of the chest area (sliding hiatus hernias) can cause gastro-oesophageal reflux disease (GORD). This is where stomach acid leaks into the oesophagus (gullet). This can damage the oesophagus, increasing the risk of the problems described below.
Damage to the lining of the oesophagus (oesophagitis) caused by stomach acid can lead to the formation of ulcers. The ulcers can bleed, causing pain and making swallowing difficult.
Ulcers can usually be successfully treated by controlling the underlying symptoms of GORD. In most cases, over-the-counter medicines calledantacids or alginates are used to treat the condition.
Repeated damage to the lining of your oesophagus can lead to the formation of scar tissue. If the scar tissue is allowed to build up, it can cause your oesophagus to become narrowed. This is known as oesophageal stricture.
An oesophageal stricture can make swallowing food difficult and painful. Oesophageal strictures can be treated by using a tiny balloon to dilate (widen) the oesophagus. This procedure is usually carried out under a local anaesthetic.
Barrett's oesophagus and cancer
Repeated damage to the oesophagus can also lead to changes in the cells lining your lower oesophagus. This is a condition known as Barrett's oesophagus.
Barrett's oesophagus does not usually cause noticeable symptoms other than those associated with GORD.
However, Barrett's oesophagus can increase your risk of developing oesophageal cancer.
In some cases, a hiatus hernia causes part of the stomach to push up next to the oesophagus. This is known as a para-oesophageal hiatus hernia. GORD doesn't usually occur in these cases, but there is a risk of the hernia becoming strangulated.
Strangulation occurs when the hernia becomes knotted and the blood supply to the area is cut off. Emergency surgery is usually required to correct the problem.