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Hiatus hernia

A hiatus hernia is when part of the upper stomach slides upwards into the chest. It does this by pushing through the natural opening in the diaphragm muscle through which the oesophagus (the pipe that goes from the mouth to the stomach) passes. Hiatus hernias are common, especially in people over 50.

Your stomach usually sits completely below your diaphragm. The diaphragm is the sheet of muscle that separates your chest (where your lungs and heart are) from your abdomen (tummy). 

Your diaphragm has an opening in it called the hiatus. Your oesophagus passes through the hiatus. A hiatus hernia develops when part of your stomach slides back up through the hiatus and into your chest.

Hiatus hernia is very common – around three in 10 people over 50 will get it. However, this number may be higher, because many people with a hiatus hernia have very mild symptoms or none at all, and may not realise that they have the condition.

There are two types of hiatus hernia, a sliding hiatus hernia and a rolling hiatus hernia. Around nine out of 10 people with a hiatus hernia have the sliding type. This is when both the stomach and the junction where your oesophagus and stomach meet slide upwards into your chest. A rolling hiatus hernia is where just part of your stomach pushes up into the chest.

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How a sliding hiatus hernia forms
When the junction between the oesophagus and the stomach, as well as a portion of the stomach itself, slides up above the diaphragm
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How a rolling hiatus hernia forms
When a portion of your stomach goes through the diaphragm and lies beside the oesophagus

Details

  • Symptoms Symptoms of hiatus hernia

    Most hiatus hernias don’t cause any symptoms. If you do get symptoms, they are unlikely to be serious.

    A sliding hiatus hernia can cause a problem called gastro-oesophageal reflux disease (GORD). This is when acid or bile in the stomach rises back up into your oesophagus.

    The most common symptom of GORD is heartburn, which causes a warm or burning sensation in your chest. The burning feeling from heartburn can go all the way up to your throat. You may be more likely to notice heartburn after smoking, drinking alcohol or coffee, or eating chocolate. It can also get worse when you bend over or when you’re lying down.

    Other symptoms of hiatus hernia and GORD include:

    • feeling sick or being sick
    • a cough or wheezing when breathing, especially at night – this is caused by breathing in the acid that has come up from your stomach
    • your mouth filling with saliva
    • finding it difficult or painful to swallow

    You can have a hiatus hernia without GORD, and you can have GORD without having a hiatus hernia, but they often go together.

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  • Diagnosis Diagnosis of hiatus hernia

    If your GP thinks you might have a hiatus hernia, he or she will ask you about your symptoms. Your GP may refer you to a gastroenterologist (a doctor who specialises in identifying and treating conditions that affect the digestive system) for tests. Some of the tests your specialist may arrange are listed below.

    • Endoscopy (also called gastroscopy). This test is done using a narrow, flexible, tube-like telescopic camera called an endoscope. The endoscope is passed down into your stomach through your mouth. Your doctor is able to see images of your oesophagus and stomach on a screen. He or she can also take a biopsy (a tissue sample) at the same time, and stretch any narrowing that has been caused by acid reflux.
    • Sometimes your doctor will arrange for you to have a barium meal X-ray. You may need this if you can’t an endoscopy isn’t suitable for you.

    A hiatus hernias is sometimes discovered when you have a chest X-ray, scan or endoscopy for something else. This is because a hiatus hernia often doesn't cause any symptoms.

  • Treatment Treatment of hiatus hernia

    Treatment for hiatus hernia generally aims to ease the symptoms of acid reflux. The treatment you need will depend on how severe your symptoms are and how much they are affecting you.

    Self-help

    You can reduce the symptoms of a hiatus hernia and prevent further problems by making the following lifestyle changes.

    • If you’re overweight or obese, lose excess weight.
    • Eat small meals often and try not to eat just before you go to bed.
    • Giving up smoking and cutting down on alcohol will help.
    • Wear loose comfortable clothes.
    • Raise the head of your bed and try not to stoop or bend down.
    • Cut down or stop eating food or drinks that make your symptoms worse. See our frequently asked questions for more information.

    Medicines

    You can take medicines to help reduce the symptoms of reflux from a sliding hiatus hernia. The most common are antacids, which work by neutralising the acid in your stomach. How well antacids work varies from person to person. If you find they don’t relieve your symptoms, your GP or pharmacist may suggest a different medicine. The two main types that you may be prescribed are called H2 receptor antagonists and proton pump inhibitors. Both of these reduce the amount of acid produced by your stomach.

    Surgery

    If you have tried other treatments and they haven’t worked, or your symptoms are severe, your doctor may suggest an operation. You will also need to have surgery if a rolling hernia becomes strangulated.

    There are a number of different types of operation to repair a hiatus hernia. They involve putting the gastro-oesophageal junction back into your abdomen and tightening up the hiatus (the opening).

    Your surgeon will also strengthen the oesophageal sphincter by wrapping the stomach around it. The oesophageal sphincter is a bundle of muscles which stops what is in your stomach from coming back out. This operation is called a fundoplication and is usually done as a laparoscopic (keyhole) procedure. See our frequently asked questions for more information.

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  • Causes Causes of hiatus hernia

    The exact reasons why you may develop a hiatus hernia aren’t fully understood. However, you’re more likely to develop one if you’re very overweight (obese). Being overweight increases the pressure in your abdomen and can push your stomach up into your chest. You’re also more at risk as you get older. This is because as get older the muscles in your diaphragm get weaker.

    Hiatus hernias are more common in women than in men. This may be related to the increased pressure in a woman’s abdomen as result of pregnancy.

  • Complications Complications of hiatus hernia

    Occasionally, a hiatus hernia can lead to more serious problems. Your oesophagus can become damaged by the acid from your stomach and this can lead to ulcers. These ulcers can be painful when you swallow and can bleed. As the ulcers heal scars can develop, which can narrow your oesophagus. This can cause food to get stuck or to come back up.

    Acid reflux can also cause a condition called Barrett’s Oesophagus. This is where the cells that line your oesophagus change and become abnormal. Over time these cells may become cancerous.

    A rolling hiatus hernia can sometimes get trapped or pinched by the diaphragm causing the blood supply to be cut off. This is called a strangulated hernia and causes severe pain. If this happens, you will need to have an operation immediately to treat it.

    Chronic oesophagitis (long-term inflammation of the lining of the oesophagus) can develop if you have acid reflux over a long period of time. The inflammation causes scarring, which can then cause the oesophagus to shrink and become shorter.

  • FAQs FAQs

    I am overweight and often get heartburn. Could I have a hiatus hernia?

    Answer

    If you’re overweight or obese, you’re more likely to get heartburn and indigestion. You’re also more likely to develop a hiatus hernia.

    Explanation

    The exact reasons why being overweight causes heartburn aren’t known. However, being overweight or obese can increase the pressure inside your abdomen (tummy) which may have an effect. Being very overweight may also affect how well the opening from your stomach to your oesophagus (the pipe that goes from your stomach to your mouth) works. Whatever the cause, acid from your stomach can flow backwards into your oesophagus. This is called acid reflux and is what causes heartburn.

    Heartburn is a common symptom of a hiatus hernia. Other symptoms include finding it difficult or painful to swallow, feeling sick or being sick and a cough or wheezing when breathing at night. Speak to your GP if you have any of these symptoms or think you might have a hiatus hernia.

    Exercising and eating healthily can help you to lose excess weight and reduce your symptoms. Try to do 150 minutes (two and a half hours) of moderate exercise over a week in bouts of 10 minutes of more. You can do this by carrying out 30 minutes on at least five days each week.

    What are the risks of surgery for a hiatus hernia?

    Answer

    As with every procedure, there are some risks associated with having surgery for a hiatus hernia. These are specific to you and differ for every person but may include feeling full and uncomfortable especially after eating and difficulty swallowing. Ask your surgeon to explain how these risks apply to you.

    Explanation

    Complications are when problems occur during or after the operation. Side-effects are the unwanted but mostly temporary effects you may get after having the procedure.

    Complications and side-effects following surgery for a hiatus hernia are rare. The main ones are listed below.

    • Feeling bloated and full, especially after you’ve eaten. Some people get uncomfortable as it’s difficult to burp after this type of surgery. This is called ‘gas-bloat syndrome’.
    • Finding it difficult or painful to swallow – this usually gets better within six weeks of having the operation.
    • Injury to the area around your stomach and diaphragm.
    • Wound infection.
    • Hernias through surgical wounds – this is where the tissues in your abdomen push up through your wound causing a bulge.
    • Bleeding in your stomach or spleen area at the time of the operation – this is rare it but will need immediate medical treatment.

    Sometimes the benefits of the operation don’t last and it may need to be done again. If your symptoms come back after your operation, talk to your surgeon.

    What medicines can I take to help me feel better if I have a hiatus hernia?

    Answer

    You can take a number of different types of medicine that should help you feel better. They work by either neutralising stomach acid or reducing the amount of acid produced in your stomach, and by protecting your stomach and oesophagus.

    Explanation

    Antacids work by counteracting or neutralising the acid in your stomach. Some antacids also cover the surface of your oesophagus and stomach which forms a protective barrier against acid.

    You won’t need a prescription for these medicines– you can buy them from a pharmacy or supermarket. They are available in tablet or liquid form. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice.

    How well antacids work varies from person to person. If you find they don’t relieve your symptoms, your GP or pharmacist may recommend a different medicine.

    Proton pump inhibitors (for example, omeprazole, lansoprazole and pantoprazole) reduce the amount of acid being produced. Histamine blockers, sometimes called H2-receptor blockers (for example, ranitidine and cimetidine), also reduce the amount of acid your stomach produces, although they don’t work as well as proton pump inhibitors. You won’t need a prescription to buy H2-receptor blockers but you will need one for proton pump inhibitors.

    Always ask your GP for advice and read the patient information leaflet that comes with your medicine.

    Which foods make the symptoms of hiatus hernia worse?

    Answer

    There are certain foods and drinks that can make your symptoms worse. These include spicy foods, alcohol and caffeine.

    Explanation

    Making changes to your lifestyle can help control the symptoms of acid reflux caused by a hiatus hernia. Some food and drink can increase the amount of acid in your stomach or relax the muscle at the bottom of the oesophagus and make heartburn worse. These include:

    • chocolate
    • spicy food
    • fatty food
    • tomato-based foods, including spaghetti sauce and salsa
    • alcoholic drinks
    • drinks that contain caffeine, such as coffee and cola

    You might find it helpful to keep a food diary so that you can start to recognise which foods make your symptoms worse. When you know what these are, you can stop eating them or have less of them.

  • Resources Resources

    Further information

    Sources

    • Simon C, Everitt H, van Dorp F. Oxford Handbook of General Practice. 3rd ed. Oxford: Oxford University Press, 2010, 394-5
    • Hiatal hernia. eMedicine. emedicine.medscape.com, published July 2013
    • Dyspepsia. Clinical Knowledge Summaries. cks.nice.org.uk, published November 2012
    • Heartburn and reflux. CORE Charity. www.corecharity.org.uk, published July 2013
    • Dyspepsia. National Institute for Health and Clinical Excellence (NICE).2004 www.nice.org.uk
    • Joint Formulary Committee. British National Formulary (online) London: BMJ group and Pharmaceutical Press. www.medicinescomplete.com, accessed 31 July 2013.
    • Laparoscopic Nissen Fundoplication. eMedicine. emedicine.medscape.com, published February 2012
    • Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease. Society of American Gastrointestinal and Endoscopic Surgeons. www.sages.org, accessed 31 July 2013
    • Start active, stay active: a report on physical activity from the four home countries’ Chief Medical Officers. Department of Health. www.gov.uk, published July 2011
    • Hiatus hernia. Merck Manuals. www.merckmanuals.com, published June 2006
    • Gastroesophageal Reflux Disease. eMedicine. emedicine.medscape.com, published May 2013
    • Hiatus hernia. PatientPlus. www.patient.co.uk, published August 2011
    • Patient Information for Laparoscopic Anti-Reflux (GERD). Society of American Gastrointestinal and Endoscopic Surgeons www.sages.org, accessed 23 October 2013
    • Overview of the esophagus. Merck Manuals. www.merckmanuals.com, published October 2007
    • Murray L, Johnston B, Lane A et al. Relationship between body mass and gastro-oesophageal reflux symptoms: The Bristol Helicobacter Project Int. J. Epidemiol. (2003) 32 (4): 645–650 ije.oxfordjournals.org
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  • Author information Author information

    Reviewed by Sarah Smith, Bupa Health Information Team, October 2013.

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