Hiatus hernia

What causes a hiatus hernia?

Doctors are not entirely sure what causes a hiatus hernia, but it may happen when the diaphragm weakens with age, or when there is extra pressure on the abdomen.

In newborn babies, a hiatus hernia can sometimes occur if the stomach or diaphragm has not developed properly.

Who is affected

A hiatus hernia can affect anyone, but it is more common in people who are:

• over 50 years of age
• overweight
• pregnant

It is estimated that a third of people over 50 have a hiatus hernia.

There is also a rare type that affects newborn babies, caused by a congenital defect of the stomach or diaphragm. Congenital means it is present from birth.

Types of hiatus hernia

There are 2 main types of hiatus hernia:

• Sliding hiatus hernia, where the hernia moves up and down, in and out of the chest area. More than 80% of hiatus hernias are this type.
• Para oesophageal hiatus hernia, also called a rolling hiatus hernia, where part of the stomach pushes up through the opening in the diaphragm next to the food pipe. About 5 to 15% of hiatus hernias are this type.

These pages mainly focus on sliding hiatus hernia. It can usually be diagnosed with an X-ray or an endoscopy, a test in which a long, thin, flexible tube fitted with a light and a video camera is used to look inside the body.

Read more about diagnosing a hiatus hernia.

Diagnosing hiatus hernia

A hiatus hernia can usually be diagnosed after a gastroscopy or X-ray.

Gastroscopy

A gastroscopy is a procedure where the inside of your body is examined using a gastroscope (a long, thin flexible tube with a light and video camera at one end), which sends images to an external monitor.

The gastroscope will be inserted into your mouth and down your throat, and will be used to help identify any problems. The procedure may be carried out using a local anaesthetic or a sedative to help you relax.

Barium meal X-ray

The barium meal X-ray, also called the barium swallow test, is an effective way of identifying a hiatus hernia.

As part of the test, you’ll 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 won’t be able to eat or drink anything for at least 6 hours before the procedure, so that your stomach and duodenum (the top of the small intestine) are empty. You may be given an injection to relax the muscles in your digestive system.

You’ll be given a white, chalky liquid containing barium to drink while lying down. This will allow the specialist 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’ll 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 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 3 large meals a day
• avoiding lying down (including going to bed) for 3 hours after eating or drinking
• removing any foods or drinks from your diet that make your symptoms worse

If a hiatus hernia isn’t causing any noticeable problems, it doesn’t usually need to be treated.

Surgery is used to repair a para-oesophageal hiatus hernia if there’s a risk of serious complications.

Read more about treating a hiatus hernia.

Further problems

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.

Read more about the complications of a hiatus hernia.

Treating 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.

Lifestyle changes

There are several things you can do yourself to 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 3 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, particularly 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; don’t use extra pillows, because this may increase pressure on your abdomen

If you’re overweight, losing weight may help to reduce the severity and frequency of your symptoms.

If you smoke, you should try to give up. Tobacco smoke can irritate your digestive system and may make your symptoms worse.

Read about stopping smoking.

Medication

A number of different medications can be used to treat symptoms of hiatus hernia. These are described below.

Antacids

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 to 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’re in extreme discomfort.

Antacids shouldn’t 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

Alginates are an alternative medicine to antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.

H2-receptor antagonists

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 (PepcidTwo) and ranitidine.

H2RAs block the effects of the chemical histamine, which your body uses to produce stomach acid. H2RAs therefore help to 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’re 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 include omeprazole, lansoprazole, rabeprazole and esomeprazole.

Most people tolerate PPIs well and side effects are uncommon. When they do occur, they’re usually mild and can 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.

Surgery

Surgery is usually only recommended for a sliding hiatus hernia (hernias that move up and down, in and out of the chest area) if the problem fails to respond to lifestyle changes and medication.

You may also want to consider surgery if you have persistent and troublesome symptoms, but don’t 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 won’t feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.

After having LNF, you should be able to leave hospital after you’ve recovered from the effects of the general anaesthetic. This is usually within 2 to 3 days. Depending on the type of job you do, you should be able to return to work within 3 to 6 weeks.

For the first 6 weeks after surgery, it’s recommended that 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 (see complications of a hiatus hernia for more information).

Complications from a hiatus hernia are rare, but they can be serious.

If you have a sliding hiatus hernia, where part of the stomach slides in and out of the chest area, it can lead to gastro-oesophageal reflux disease, often called GORD. This happens when stomach acid leaks upward into the oesophagus, the food pipe connecting your mouth to your stomach. Over time, this acid can damage the oesophagus and raise the risk of further problems.

Oesophageal ulcers

When stomach acid repeatedly irritates and damages the lining of the oesophagus, a condition called oesophagitis, it can lead to ulcers forming. These ulcers may bleed, and they can cause pain and make swallowing difficult.

The good news is that ulcers can usually be treated well by getting the underlying GORD symptoms under control. Most people find relief with over the counter medicines such as antacids or alginates.

Ask your doctor for more guidance on treating GORD.

Oesophageal stricture

If the lining of your oesophagus is damaged again and again, scar tissue can build up. Over time, this scarring can cause the oesophagus to narrow, a condition known as oesophageal stricture.

This narrowing can make swallowing food difficult and painful. Fortunately, it can be treated using a small balloon to gently widen the oesophagus. This procedure is usually done under local anaesthesia, so you stay awake but the area is numbed.

Barrett's oesophagus and cancer

Repeated damage to the oesophagus can also cause changes in the cells lining its lower part. This is known as Barrett's oesophagus.

It doesn't usually cause any noticeable symptoms beyond those of GORD itself. However, it's important to know that Barrett's oesophagus can increase the risk of developing oesophageal cancer.

If you have reflux symptoms that continue for more than 3 weeks, it's best to speak with your doctor, as further tests may be needed to check what's going on.

Strangulated hernia

In some cases, part of the stomach pushes up beside the oesophagus instead of through it. This is called a para oesophageal hiatus hernia. GORD doesn't usually occur with this type, but there is a risk that the hernia could become strangulated.

Strangulation happens when the hernia becomes tightly knotted, cutting off its blood supply. This is a medical emergency, and surgery is usually needed right away to correct the problem.