Overview

A hiatal hernia occurs when the upper part of your stomach bulges through the large muscle separating your abdomen and chest (diaphragm).

Your diaphragm has a small opening (hiatus) through which your food tube (esophagus) passes before connecting to your stomach. In a hiatal hernia, the stomach pushes up through that opening and into your chest.

A small hiatal hernia usually doesn't cause problems. You may never know you have one unless your doctor discovers it when checking for another condition.

But a large hiatal hernia can allow food and acid to back up into your esophagus, leading to heartburn. Self-care measures or medications can usually relieve these symptoms. A very large hiatal hernia might require surgery.

Symptoms

Most small hiatal hernias cause no signs or symptoms. But larger hiatal hernias can cause:

• Heartburn
• Regurgitation of food or liquids into the mouth
• Backflow of stomach acid into the esophagus (acid reflux)
• Difficulty swallowing
• Chest or abdominal pain
• Feeling full soon after you eat
• Shortness of breath
• Vomiting of blood or passing of black stools, which may indicate gastrointestinal bleeding

When to see a doctor

See your doctor if you have any persistent signs or symptoms that worry you.

Causes

A hiatal hernia occurs when weakened muscle tissue allows your stomach to bulge up through your diaphragm. It's not always clear why this happens. But a hiatal hernia might be caused by:

• Age-related changes in your diaphragm
• Injury to the area, for example, after trauma or certain types of surgery
• Being born with an unusually large hiatus
• Persistent and intense pressure on the surrounding muscles, such as while coughing, vomiting, straining during a bowel movement, exercising or lifting heavy objects

Risk factors

Hiatal hernias are most common in people who are:

• Age 50 or older
• Obese

Diagnosis

A hiatal hernia is often discovered during a test or procedure to determine the cause of heartburn or chest or upper abdominal pain. These tests or procedures include:

• X-ray of your upper digestive system. X-rays are taken after you drink a chalky liquid that coats and fills the inside lining of your digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach and upper intestine.
• Upper endoscopy. Your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat, to examine the inside of your esophagus and stomach and check for inflammation.
• Esophageal manometry. This test measures the rhythmic muscle contractions in your esophagus when you swallow. Esophageal manometry also measures the coordination and force exerted by the muscles of your esophagus.

Treatment

Most people with a hiatal hernia don't experience any signs or symptoms and won't need treatment. If you experience signs and symptoms, such as recurrent heartburn and acid reflux, you may need medication or surgery.

Medications

If you experience heartburn and acid reflux, your doctor may recommend:

• Antacids that neutralize stomach acid. Antacids, such as Mylanta, Rolaids and Tums, may provide quick relief. Overuse of some antacids can cause side effects, such as diarrhea or sometimes kidney problems.
• Medications to reduce acid production. These medications — known as H-2-receptor blockers — include cimetidine (Tagamet HB), famotidine (Pepcid AC) and nizatidine (Axid AR). Stronger versions are available by prescription.
• Medications that block acid production and heal the esophagus. These medications — known as proton pump inhibitors — are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24HR) and omeprazole (Prilosec, Zegerid). Stronger versions are available in prescription form.

Surgery

Sometimes a hiatal hernia requires surgery. Surgery is generally used for people who aren't helped by medications to relieve heartburn and acid reflux, or have complications such as severe inflammation or narrowing of the esophagus.

Surgery to repair a hiatal hernia may involve pulling your stomach down into your abdomen and making the opening in your diaphragm smaller or reconstructing an esophageal sphincter. In some cases, hiatal hernia surgery is combined with weight-loss surgery, such as a sleeve gastrectomy.

Surgery may be performed using a single incision in your chest wall (thoracotomy) or using a minimally invasive technique called laparoscopy. In laparoscopic surgery, your surgeon inserts a tiny camera and special surgical tools through several small incisions in your abdomen. The operation is then performed while your surgeon views images from inside your body that are displayed on a video monitor.

Lifestyle and home remedies

Making a few lifestyle changes may help control the symptoms and signs caused by a hiatal hernia. Try to:

• Eat several smaller meals throughout the day rather than a few large meals
• Avoid foods that trigger heartburn, such as fatty or fried foods, tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine
• Avoid lying down after a meal or eating late in the day
• Maintain a healthy weight
• Stop smoking
• Elevate the head of your bed 6 inches (about 15 centimeters)

Preparing for an appointment

You'll probably see a family doctor or general practitioner.

If you've been diagnosed with a hiatal hernia and your problems persist after you make lifestyle changes and start medication, you might be referred to a doctor who specializes in digestive diseases (gastroenterologist).

What you can do

• Be aware of any pre-appointment restrictions, such as restricting your diet before your appointment.
• Write down your symptoms, including any that may seem unrelated to the reason why you scheduled the appointment.
• Make a list of all the medications, vitamins and supplements you're taking.
• Write down your key medical information, including other conditions.
• Write down key personal information, including any recent changes or stressors in your life.
• Write down questions to ask your doctor.
• Ask a relative or friend to accompany you, to help you remember what the doctor says.

Questions to ask your doctor

• What caused my hiatal hernia?
• What tests do I need? Is there any special preparation for them?
• Will I need treatment? What are my options, and the benefits and risks of each?
• I have other health problems. How can I best manage these conditions together?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions that occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may leave time to go over points you want to spend more time on. You may be asked:

• When did you begin experiencing symptoms? How severe are they?
• Have your symptoms been continuous or occasional?
• What, if anything, seems to improve or worsen your symptoms?