Hiatal Hernia: The Complete Guide
A hiatal hernia occurs when part of the stomach moves up into the chest through the oesophageal opening of the diaphragm. Its main symptoms are heartburn and reflux. Most cases are managed with lifestyle changes and medication; laparoscopic surgery is reserved for selected patients.
What is a hiatal hernia?
The diaphragm is a dome-shaped muscle separating the chest from the abdomen; the oesophagus passes through its hiatus. When the hiatus widens, part of the stomach (sometimes other organs) moves into the chest — a hiatal hernia. Unlike other hernia types, it causes no external bulge and is recognised by digestive symptoms.
Types
| Type | Description | Approx. share |
|---|---|---|
| Type I (sliding) | The gastro-oesophageal junction slides into the chest | ~95% |
| Type II (paraoesophageal) | The fundus rises beside the oesophagus | Rare |
| Type III (mixed) | Sliding + paraoesophageal | Most paraoesophageal hernias |
| Type IV | Other organs (colon, spleen) herniate too | Rare |
Types II–IV (paraoesophageal hernias) carry the risk of gastric volvulus and strangulation.
Causes
Ageing, obesity, pregnancy, chronic cough, constipation and vomiting, heavy lifting, congenital factors and previous surgery in the area.
Symptoms
Reflux symptoms: heartburn, regurgitation of food or acid, belching, bloating, early satiety, chronic cough, hoarseness, recurrent sore throat and night-time asthma.
Large hernias: difficulty swallowing, chest pain (always exclude heart disease first), breathlessness after meals, and iron-deficiency anaemia from Cameron ulcers.
Emergency: sudden severe chest or upper abdominal pain with inability to vomit or swallow may indicate gastric volvulus — go to the emergency department.
Diagnosis
Upper endoscopy, barium swallow, CT for large hernias, and oesophageal manometry and 24-hour pH monitoring before surgery.
Treatment
Lifestyle
Weight loss, small frequent meals, no eating 2–3 hours before bed, raising the head of the bed 15–20 cm, limiting trigger foods (fatty and fried foods, chocolate, caffeine, mint, spicy food, fizzy drinks), stopping smoking and avoiding tight belts.
Medication
Proton pump inhibitors (PPIs) are the most effective; H2 blockers, antacids and alginates help milder symptoms. Medication treats symptoms but does not repair the hernia.
Laparoscopic surgery
Indications: reflux not controlled by medication or with complications, patients unwilling to take lifelong medication, symptomatic paraoesophageal hernias, and complications such as bleeding, anaemia or volvulus.
Steps: reduce the stomach and excise the sac, close the hiatus (cruroplasty, sometimes mesh-reinforced in selected cases), and perform a fundoplication — Nissen (360°), Toupet (270°) or partial anterior wrap. Hospital stay is 1–2 days, with a liquid then soft diet for a few weeks. See types of hernia surgery.
Frequently asked questions
Is a hiatal hernia dangerous?
Does a hiatal hernia go away?
What is the best sleeping position with a hiatal hernia?
Scientific references
⚠ This website is for health education and does not replace a medical examination. If you develop sudden severe pain at a hernia, vomiting, or the bulge changes colour, go to the emergency department immediately.