Hiatus hernia

A hiatus hernia, also called a hiatal hernia, happens when part of the stomach squeezes up into the chest through an opening in the diaphragm. This opening is called the 'hiatus'.

The diaphragm is a large, thin sheet of muscle that sits between the chest and the abdomen (tummy).

A hiatus hernia rarely causes any symptoms you'd notice. But it can lead to a problem called gastro-oesophageal reflux disease (GORD).

In GORD, stomach acid leaks up into the oesophagus (the tube that carries food to the stomach). This can happen when a hiatus hernia stops the valve at the bottom of the oesophagus from working properly.

Because the oesophagus has no protection against stomach acid, it can become badly irritated. You may then have heartburn, chest pain, an unpleasant sour taste in your mouth, or trouble swallowing (dysphagia).

If your GORD symptoms are frequent and severe, you should see your doctor.

Doctors don't know exactly what causes a hiatus hernia. It may come from the diaphragm growing weaker with age, or from pressure on the abdomen.

A hiatus hernia can also appear in newborn babies, when the stomach or the diaphragm doesn't develop properly.

Hiatus hernia can affect anyone, but you're more likely to have one if you are:

• over 50 years of age
• overweight
• pregnant

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. It's caused by a congenital defect of the stomach or diaphragm, and congenital simply means the problem is present from birth.

There are 2 main types of hiatus hernia:

• sliding hiatus hernias, which move up and down, in and out of the chest area (more than 80% of hiatus hernias are of this type)
• para-oesophageal hiatus hernias, also called rolling hiatus hernias, where part of the stomach pushes up through the hole in the diaphragm next to the oesophagus (about 5 to 15% of hiatus hernias are of this type)

These pages mainly focus on sliding hiatus hernias. A doctor can usually diagnose them with an X-ray or an endoscopy. In an endoscopy, a long, thin, flexible tube with a light and a video camera at one end is used to look at the inside of the body.

Read more about diagnosing a hiatus hernia.

When you have a sliding hiatus hernia, treatment usually focuses on easing the symptoms of GORD, such as heartburn.

Lifestyle changes and medicine are the preferred treatments. Surgery is usually only recommended if you'd rather not stay on medicine for the long term, 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.

A para-oesophageal hiatus hernia is different. Surgery is used to repair it if there's a risk of serious complications.

A hiatus hernia rarely causes complications. But if stomach acid keeps leaking up and damages the oesophagus over a long time, it can lead to ulcers, scarring and changes to the cells of the oesophagus. Those cell changes can increase your risk of oesophageal cancer.

Doctors can usually diagnose a hiatus hernia after a gastroscopy or an X-ray.

A gastroscopy is a procedure that lets a doctor look inside your body using a gastroscope. This is a long, thin, flexible tube with a light and a video camera at one end, and the camera sends pictures to a monitor outside your body.

The doctor passes the gastroscope in through your mouth and down your throat, and uses it to help find any problems. You may be given a local anaesthetic or a sedative to help you relax during the procedure.

A barium meal X-ray, also called a barium swallow test, is an effective way to find a hiatus hernia.

For 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 it moves down into your digestive system, the doctor takes a series of X-rays to look for any problems.

Before a barium meal X-ray, you won't be able to eat or drink anything for at least 6 hours. This keeps your stomach and duodenum (the top of the small intestine) empty. An injection to relax the muscles in your digestive system may also be given.

The barium is a white, chalky liquid, and you drink it while lying down. It lets the specialist see your stomach more easily on an X-ray monitor, along with any ulcers or abnormal growths. The bed may be tipped slightly during the test so that the barium fills every area of your stomach.

A barium swallow usually takes about 15 minutes. Afterwards, you can eat and drink as normal, though it helps to drink more water to flush the barium out of your system.

Some people feel slightly sick after a barium meal X-ray, and the barium may cause constipation. Stools can also look white for a few days, as the barium passes through.

You usually only need treatment for a hiatus hernia if it's causing problems.

Most people with a hiatus hernia run into trouble only when the hernia leads to gastro-oesophageal reflux disease (GORD). GORD can cause symptoms such as heartburn and an unpleasant taste in your mouth.

Lifestyle changes and medicine are the preferred treatments. Surgery may be used instead of long-term medicine, or if the other treatments don't work.

There are several things you can do yourself to help ease the symptoms of GORD caused by a hiatus hernia. These include:

• eating smaller, more frequent meals, rather than three large meals a day
• not lying down (including going to bed) for at least 3 hours after eating or drinking
• not 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
• not 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 how severe your symptoms are and how often they come.

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

Several different medicines can be used to treat the symptoms of a hiatus hernia. They are described below.

Antacid medicines can ease some of the symptoms of hiatus hernia. You can buy them as a liquid or as tablets, and you either swallow them or chew them. Once they reach the oesophagus and stomach, they neutralise the stomach acid and make it less acidic.

They don't work for everyone, though. If your symptoms carry on, or you're in extreme discomfort, antacids are not a long-term answer.

Don't take antacids at the same time as other medicines. They can stop your body from absorbing the other medicines properly, and they may also damage the special coating on some types of tablets. Ask your doctor or pharmacist for advice.

Alginates are another kind of medicine you can take instead of antacids. They form a protective coating that shields the lining of your stomach and oesophagus from stomach acid.

If you have a hiatus hernia that is causing GORD, your doctor may recommend a medicine called an H2-receptor antagonist (H2RA). Examples of H2RAs include cimetidine, famotidine (PepcidTwo) and ranitidine.

Your body uses a chemical called histamine to produce stomach acid. H2RAs block the effects of histamine, so they help to reduce the amount of acid in your stomach.

Side effects of H2RAs are uncommon. But some people may get diarrhoea, headaches, tiredness or a rash.

Some H2RAs are available over the counter at pharmacies. These types of HR2As are taken in a lower dosage than the ones you get on prescription. If you're not sure whether these medicines are suitable for you, ask your doctor or pharmacist.

Your doctor may prescribe a medicine called a proton-pump inhibitor (PPI) for hiatus hernia. PPIs work by reducing the amount of acid your stomach produces. The ones you may be given include omeprazole, lansoprazole, rabeprazole and esomeprazole.

Most people tolerate PPIs well, and side effects are uncommon. When they do happen, they're usually mild. They can include headaches, diarrhoea, feeling sick or constipation.

To keep side effects down, your doctor will prescribe the lowest dose of a PPI that they think will work. If the dose you've been given doesn't work, tell your doctor, because a stronger dose may be needed.

Doctors usually recommend surgery for a sliding hiatus hernia (one that moves up and down, in and out of the chest area) only if the problem doesn't respond to lifestyle changes and medicine.

You may also want to think about surgery if your symptoms keep coming back and trouble you, but you don't want to take medicine for a long time.

Before surgery, you may need more tests. One checks how well the oesophagus moves (manometry). Another checks how much acid is coming back up (24-hour oesophageal pH studies).

A laparoscopic Nissen fundoplication (LNF) is one of the most common operations used to treat GORD and sliding hiatus hernias.

LNF is a type of keyhole surgery. The surgeon makes a few small cuts in your abdomen, then fills it with carbon dioxide gas so there's room to work.

During the operation, the stomach is put back in its correct position and the diaphragm around the lower part of the oesophagus is tightened. This should stop acid from moving back up out of your stomach.

You'll be under general anaesthetic, so you won't feel any pain or discomfort. The surgery takes 60 to 90 minutes.

Once you've recovered from the general anaesthetic, you should be able to leave hospital. That's usually within 2 to 3 days. Depending on the kind of job you do, you can expect to go back to work within 3 to 6 weeks.

For the first 6 weeks after surgery, it's recommended that you eat only soft food, such as mince, mashed potatoes or soup. Avoid hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.

The common side effects of LNF are difficulty swallowing (dysphagia), belching, bloating and flatulence. These usually settle over a few months. In about 1 in 100 cases, though, they carry on, and further corrective surgery may be needed.

A para-oesophageal hiatus hernia is when part of the stomach pushes up through the hole in the diaphragm, right beside the oesophagus. If you have one, your doctor may recommend surgery. The aim is to lower the risk of the hernia becoming strangulated (the complications of a hiatus hernia are described elsewhere in this article).

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

A sliding hiatus hernia is one that moves up into the chest and back down again. It can cause gastro-oesophageal reflux disease (GORD), where stomach acid leaks up into the oesophagus (the gullet). Over time this acid can damage the oesophagus, and that damage raises the risk of further problems.

When stomach acid damages the lining of the oesophagus (this is called oesophagitis), ulcers can form. These oesophageal ulcers can bleed, which causes pain and makes swallowing difficult.

Ulcers can usually be treated well by getting the underlying symptoms of GORD under control. In most cases, antacids or alginates are used. These are medicines you can buy without a prescription.

If the lining of your oesophagus is damaged again and again, scar tissue can form. When that scar tissue builds up, it can make the oesophagus narrower. This is called an oesophageal stricture.

A stricture can make swallowing food difficult and painful. It can be treated by using a tiny balloon to dilate (widen) the oesophagus. The procedure is usually done under a local anaesthetic.

If the oesophagus is damaged again and again, the cells lining its lower part can change. This condition is called Barrett's oesophagus.

Barrett's oesophagus doesn't usually cause any symptoms of its own, apart from those linked to GORD. But it can raise your risk of developing oesophageal cancer.

If your reflux symptoms carry on for more than 3 weeks, talk to your doctor, because you may need some investigations.

Sometimes a hiatus hernia pushes part of the stomach up next to the oesophagus. This is known as a para-oesophageal hiatus hernia. GORD doesn't usually happen with this type, but there's a risk that the hernia will become strangulated.

Strangulation happens when the hernia gets knotted and the blood supply to the area is cut off. Emergency surgery is usually needed to correct the problem.