Hiatal Hernias - Causes and Treatment

Two Types of Hiatal Hernia Can Produce Symptoms

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A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm and up into the chest. This opening is called an esophageal hiatus or diaphragmatic hiatus. The opening in the diaphragm where the esophagus connects with the stomach acts as an additional sphincter around the lower part of the esophagus.

Normally the hiatus and the lower esophageal sphincter (LES) rely on each other to keep stomach contents from backing up into the esophagus.

It is believed that a hiatal hernia can weaken the LES, thus, making it easier for stomach acid to back up into the esophagus.

The Two Types of Hiatal Hernias

There are two categories of hiatal hernias: sliding and paraesophageal. A sliding hiatal hernia is a type of a hernia in which the gastroesophageal junction and part of the stomach slides into the chest. This may occur due to the weakening of the anchors of the esophagus to the diaphragm caused by years of longitudinal esophageal muscle contractions, or from increased pressure in the abdomen.

This junction and part of the stomach reside permanently in the chest, or just "slide" into the chest during swallowing. As an individual swallows, the esophagus contracts shortens and pulls on the stomach. After the swallow, the junction falls back into the abdomen. Approximately 90 percent of all Hiatal hernias are sliding Hiatal hernias.

A paraesophageal hernia is one in which the gastroesophageal junction remains where it belongs, but part of the stomach is squeezed up into the chest beside the esophagus.

These hernias remain in the chest at all times. With this type of a hernia, complications such as incarceration and strangulation can occur.

Incarceration is when a hernia is stuck and being squeezed. Strangulation results from the lack of blood supply, leading to the death of the tissues involved after incarceration persists for too long.

Surgical intervention is required.

What Causes a Hiatal Hernia

The cause of a hiatal hernia is unknown, but it is thought that they may be caused by the result of the weakening of the supporting tissue. Increasing age, obesity, and smoking are known risk factors in adults. Other possible associations include:

  • Pregnancy
  • Persistent pressure around the abdomen, such as from wearing tight clothing or a belt
  • Sudden physical exertion, such as weight lifting
  • Abdominal injury that causes a hole or tear in the diaphragm
  • Constipation or straining during bowel movements
  • Vomiting

Symptoms of a Hiatal Hernia

A hiatal hernia by itself rarely causes symptoms. In fact, approximately 50 percent of individuals with a hiatal hernia never experience symptoms. For those individuals who do experience symptoms, the pain and discomfort they feel is usually due to the reflux of stomach acid into the esophagus, air or bile.

Most small sliding hernias are asymptomatic. However, symptoms can include:

  • Heartburn that worsens when bending over or lying down shortly after eating
  • Regurgitation (the backflow of stomach contents into the back of the throat)
  • Vomiting
  • Gastric reflux (the backflow of stomach contents into the esophagus)
  • Sour or bitter taste in the mouth
  • Frequent belching
  • Frequent hiccuping

Paraesophageal hernias also tend to be asymptomatic. However, they may include any of the following intermittent symptoms:

  • Nausea
  • Retching
  • Chest pain radiating from below the breastbone (the sternum)
  • Sensation of pressure in the chest
  • Bloated feeling after eating
  • Abdominal discomfort
  • Abdominal pressure, especially soon after eating
  • Discomfort or pain in the stomach
  • Discomfort or pain in the esophagus
  • Gas
  • Unexplained coughing
  • Difficulty swallowing

How Hiatal Hernias Are Diagnosed

There are quite a few tests that diagnose a hiatal hernia, including a blood test, a barium x-ray, an upper endoscopy and a manometry.

The following tests are one's doctors routinely use:

  • Barium x-rays. Also known as a barium swallow, this is a diagnostic x-ray in which the patient drinks a chalky liquid that contains barium, revealing a range of abnormalities that occur in the digestive tract, including Hiatal hernias, in the x-ray.
  • Upper endoscopy. The upper endoscopy—also known as an esophagogastroduodenoscopy, or EGD—allows the doctor to examine the inside of the patient's esophagus, stomach, and duodenum (the first part of the small intestine) with an instrument called an endoscope.

Treatment for Hiatal Hernias

Surgery is rarely necessary for sliding hiatal hernias. The main purpose of treatment is to provide symptom relief, which can be done by making the following lifestyle changes:

  • Eat smaller, more frequent meals.
  • Avoid foods and beverages that can cause acid reflux symptoms.
  • Don't eat within 3 hours of going to bed.
  • Elevate the head of your bed 4 to 8 inches.
  • Don't wear tight clothing or belts around your waist.
  • Avoid bending or stooping after meals.
  • Avoid constipation. Talk to your doctor if you have a problem with this.
  • Don't do any heavy lifting.
  • Lose weight.
  • Stop smoking.
  • Take any medications the doctor prescribes.

In the case of paraesophageal hernias, early surgical intervention is best, given the risk of serious complications, which include:

  • Pulmonary aspiration or pulmonary compromise due to displacement of the lung by a hernia
  • Incarceration or strangulation of a hernia
  • Bleeding in the setting of incarceration or gastric ulceration


"Facts & Fallacies about Heartburn and GERD." The American College of Gastroenterology. 27 Jul 2007

NIH. Acid Reflux (GER & GERD) in Adults. NIDDK. https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults

NIH.  Hiatal hernia. MedlinePlus. https://medlineplus.gov/ency/article/001137.htm