Symptoms of a Hiatal Hernia

Woman holding stomach, cropped view
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A hiatal hernia, also known as a stomach hernia, most often affects people over 50. As many as 90 percent of people with one will experience no symptoms. Among those who do, heartburn, abdominal discomfort, throat irritation, belching, and regurgitation are common. While symptoms like these can be aggravating, they are usually not serious. With that being said, on rare occasion, large herniations can develop, causing severe complications and requiring emergency treatment.

Frequent Symptoms

Generally speaking, small herniation of the stomach is not inherently harmful and is unlikely to cause any direct pain or discomfort. What a hiatal hernia can do is alter the structures and mechanisms that keep food and acids where they belong.

Key to this problem is a structure called the lower esophageal sphincter (LES). When a hiatal herniation occurs, it can change the position of this valve, allowing the contents of the stomach to backflow into the esophagus (known as reflux). Related, intermittent symptoms can include:

  • Heartburn
  • Regurgitation
  • Belching or hiccuping shortly after eating
  • A stinging sensation in the throat
  • A sour or bitter taste in the mouth
  • Bad breath

Generally speaking, it is only when a hernia gets larger that it can manifest in this way. If the LES weakens even further, as it can happen with age, related symptoms can get progressively worse.

People with a hiatal hernia are more likely to develop gastroesophageal reflux disease (GERD), a chronic form of reflux that can interfere with quality of life.

The persistence of GERD symptoms can lead to a chronic cough, chest pain, asthma, and progressive damage to your tooth enamel.

Complications

Broadly speaking, there are two types of hiatal hernia: a sliding hiatal hernia and a paraesophageal hernia. While a sliding hernia is the most common, accounting for around 95 percent of all diagnoses, a paraesophageal hernia is potentially the more serious of the pair.

With a sliding hiatal hernia, the junction of the esophagus and stomach (referred to as the gastroesophageal junction) and part of the stomach will protrude through a hole in the diaphragm, called the hiatus. This is the space through which the esophagus passes. It is called "sliding” because the herniated part of the stomach can slide in and out of the chest cavity as you swallow.

With a paraesophageal hernia, only the stomach bulges through. While many paraesophageal hernias are simply the progression of a sliding hernia, others can occur suddenly if there is a structural weakness in the diaphragm.

Unlike a sliding hernia, a paraesophageal hernia doesn't readily slide in and out of the hiatus. Rather, it can get progressively larger and slip even further into the chest cavity as time goes by. It is at this latter stage that the complications can become serious and, in rare cases, life-threatening.

Complications may include esophageal compression, gastric obstruction, strangulation, and an extremely rare condition known as an intrathoracic stomach.

Esophageal Compression

Compression of the esophagus can occur as the hernia presses against the wall of the feeding tube. When this happens, food can get stuck in the esophagus, causing chest pain after eating and difficulty swallowing (dysphagia).

While esophageal compression is not considered a medical emergency, it may require medications to alleviate or prevent the worsening of symptoms.

Incarcerated Hiatal Hernia

Incarceration occurs when the herniated portion of the stomach becomes trapped ​during the hiatus. In some cases, the symptoms of incarceration may be chronic but minimal (mostly a sensation of chest pressure as food passes through the upper digestive tract). In others, it can cause obstruction or impede blood circulation. Incarceration itself is not a medical emergency unless a severe obstruction occurs.

Volvulus

Volvulus is a term used to describe when a herniated stomach twists more 180 degrees, causing severe gastric obstruction.

Symptoms may include dysphagia, chest pain after eating, an ability to belch, and vomiting.

If symptoms are allowed to progress, they can cause upper abdominal pain and distention, vomiting leading to nonproductive retching, and gastric bleeding (due to the abnormally increased blood pressure). Acute symptomatic volvulus generally occurs in people over age 50 and is considered a medical emergency with a 30 percent to 50 percent risk of mortality.

Strangulation

Strangulation describes the cutting off the blood supply to the stomach, either due to volvulus or incarceration. This, too, is considered a medical emergency as the blockage can result in rapid cell death (necrosis) and organ damage.

Symptoms include a sudden, sharp chest pain; fever; fatigue; bloating; vomiting; an inability to pass gas; constipation; warmth or redness over the herniation; rapid heart rate; and bloody or tarry stools (due to gastrointestinal bleeding). If not treated immediately, strangulation can lead to gangrene, shock, and death.

Intrathoracic Stomach

An intrathoracic stomach is a rare condition in which the stomach slips entirely into the chest cavity. Oddly, not all cases cause symptoms. The most common signs are a shortness of breath (dyspnea) and a feeling of chest fullness and pressure. Other symptoms can include vomiting, retching, dysphagia, gastrointestinal bleeding, and aspiration pneumonia (caused when food is coughed up into the lungs).

The enlarged hiatal gap can cause other organs to slip into the chest cavity, including the pancreas, liver, or colon. Surgery in the only means to correct this rare but serious complication.

When to See a Doctor

The vast majority of hiatal hernias can be easily managed with over-the-counter medications, weight loss, and an adjustment to your diet. Hiatal hernias generally do not to need to be medically managed unless the symptoms are persistent or worsening.

With that being said, you should see if a doctor if your symptoms fail to improve despite treatment. In some cases, stronger prescription drugs and other interventions may be needed.

On the other hand, you should seek immediate medical care if reflux symptoms are accompanied by high fever (over 100.4 degrees), severe chest pain, rapid heart rate, non-productive retching, or bloody stools. These may be the signs of a severe and potentially life-threatening hernial complication.

Sources:

Polomsky, M.; Jones, C.; Sepesi, B. et al. "Should elective repair of intrathoracic stomach be encouraged?" J Gastroint Surg Off J Soc Surg Aliment Tract. 2010; 14(2):203-10. DOI: 10.1007/s11605-009-1106.

Roman, S. "The diagnosis and management of hiatus hernia." BMJ. 2014; 349:g6154. DOI: 10.1136/bmj.g6154.

Shukla, R.; Mandal, K.; Maltra, S. et al. "Gastric volvulus with partial and complete gastric necrosis." J Indian Assoc Pediatr Surg. 2014; 19(1):49-51. DOI: 10.4103/0971-9261.125968.

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). "Guidelines for the Management of Hiatal Hernia." Los Angeles, California; issue April 2013.