Hiatal hernia

What is a hiatal hernia?

A hiatal hernia is when part of the stomach moves up into the chest through the hiatus, the opening in the diaphragm for the food pipe. The sliding type, where the top of the stomach slides upwards, accounts for about 95 percent. The rarer paraoesophageal type sits alongside the food pipe and can twist.

The diaphragm is the sheet of muscle that separates the chest from the abdomen. The food pipe (oesophagus) passes through an opening in it, called the hiatus, to join the stomach. In a sliding hiatal hernia, the most common type, the top of the stomach and lower food pipe slide up into the chest. In a paraoesophageal hernia, part of the stomach moves up alongside the food pipe and can twist, which is rarer but can cut off its blood supply.

What causes a hiatal hernia?

The exact cause of a hiatal hernia is not known. Weakening of the diaphragm with age and raised pressure in the abdomen from obesity, pregnancy, straining or chronic coughing all contribute. Smoking is linked to a higher risk, and some people are born with a larger opening or have had an injury to the diaphragm.

• Weakness of the diaphragm muscles with age
• Raised pressure in the abdomen from obesity, pregnancy, chronic straining or coughing
• Smoking, which is linked to a higher risk
• Being born with a larger opening than usual
• Injury to the diaphragm

What are the symptoms?

Many hiatal hernias cause no symptoms. When they do, symptoms are usually those of acid reflux: heartburn after eating, bringing up food or bitter fluid, burping, sore throat or cough, and difficulty swallowing. A paraoesophageal hernia can cause chest or upper abdominal pain, vomiting or breathlessness.

• Heartburn, a burning feeling in the chest, often after eating
• Bringing up food or bitter fluid into the mouth
• Frequent burping, a sour taste, or a persistent sore throat or cough
• Difficulty or pain when swallowing
• With a paraoesophageal hernia: chest or upper abdominal pain, vomiting or breathlessness

When should I see a doctor about a hiatal hernia?

See a doctor if reflux symptoms last more than three weeks, are severe, or do not improve with pharmacy medicines. Seek prompt care for weight loss, difficulty swallowing, frequent vomiting or blood in vomit. Sudden chest or upper abdominal pain with vomiting needs emergency care, as the stomach may be twisted.

The warning signs below need prompt attention.

• Losing weight without trying
• Swallowing becoming difficult
• Frequent vomiting
• Vomiting blood or passing black stools
• Sudden chest or upper abdominal pain with vomiting, which may mean a twisted hernia

How is it diagnosed?

A hiatal hernia is usually diagnosed by gastroscopy, where a thin camera is passed through the mouth into the food pipe and stomach. It can also be seen on a barium swallow X-ray, CT or other imaging. Tests are generally arranged when symptoms persist despite treatment or warning signs are present.

• A history of reflux symptoms and your response to treatment so far
• Gastroscopy, a camera passed through the mouth into the food pipe and stomach
• Barium swallow X-ray
• CT scan or other imaging in selected cases

How is a hiatal hernia treated?

Most hiatal hernias are managed with smaller meals, not eating late, raising the head of the bed, weight loss and medicines that reduce stomach acid. Keyhole surgery repairs the hiatus and wraps part of the stomach around the food pipe when symptoms persist. For a paraoesophageal hernia, surgery may be recommended for symptoms or complications; if it causes no symptoms, surgery and monitoring are discussed.

• Eating smaller meals and not eating within 3 to 4 hours of bedtime
• Raising the head of the bed by 10 to 20 cm, losing weight if overweight, and stopping smoking
• Antacids or alginates for short-term relief
• Prescription medicines that reduce stomach acid
• Keyhole surgery to repair the hiatus and wrap part of the stomach around the lower food pipe, for persistent symptoms
• Surgery for a paraoesophageal hernia that causes symptoms or complications; for one causing no symptoms, surgery and monitoring are discussed

What are the risks and complications?

Complications include stomach contents being breathed into the lungs, and a large hernia can cause slow bleeding and anaemia. A paraoesophageal hernia can rarely twist and lose its blood supply. After surgery, bloating, wind and swallowing difficulty are common for a few months, and some people need further surgery.

• Stomach contents being breathed into the lungs (aspiration)
• Slow bleeding and iron deficiency anaemia with a large hernia
• Twisting and loss of blood supply to the stomach in a paraoesophageal hernia, which is uncommon
• After surgery: bloating, wind and difficulty swallowing for a few months
• A chance of needing further surgery