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Hiatal Hernia

A hiatal hernia occurs when the top of the stomach pushes through a weak spot or hole in the diaphragm. Common symptoms include acid reflux or GERD. These hernias rarely need treatment, but doctors may recommend acid-reducing medicines or surgery for serious cases.

Last Modified: May 25, 2021
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What Is a Hiatal Hernia?

Unlike ventral or inguinal hernias that occur when organs or tissues push through the abdominal wall, a hiatal hernia happens when part of the stomach pushes through an opening in the diaphragm and into the chest cavity.

The diaphragm is a muscle that separates the abdomen from the chest cavity. It also helps keep stomach acid from backing up into the esophagus. Hiatal hernias can allow acid to back up into the esophagus and cause acid reflux symptoms.

“Statistics reveal that 60 percent of adults will have some degree of a hiatal hernia by age 60, and even these numbers do not reflect the real prevalence of the condition because many hiatal hernias can be asymptomatic.”

Types

There are two main types of hiatal hernia: Sliding hiatal hernia and paraesophageal hiatal hernia.

Sliding Hiatal Hernia

Sliding hiatal hernias are common, and about one in four adults have them by age 40, according to Medical College of Wisconsin. In this type of hernia, the point where the esophagus meets the top part of the stomach slides up into the chest cavity.

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About 95 percent of hiatal hernias are sliding hernias.

Paraesophageal Hiatal Hernia

In a paraesophageal hiatal hernia, more of the stomach pushes up through the opening in the diaphragm.

These hernias are more at risk of becoming incarcerated or strangulated. This means a part of the stomach twists or gets squeezed by surrounding muscles, cutting off blood flow or causing an obstruction. Strangulated hernias require emergency surgery.

Hiatal Hernia Symptoms

Most small hiatal hernias don’t have symptoms. These hernias are common, but less than 10 percent of people have symptoms, according to Johns Hopkins Medicine.

Common hiatal hernia symptoms resemble GERD or acid reflux symptoms. Symptoms such as chest pain and shortness of breath could be a sign of a heart problem and shouldn’t be ignored.

Hiatal hernia symptoms include:
  • Abdominal pain
  • Acid reflux
  • Chest pain
  • Feeling full immediately after eating small amounts
  • Food or liquids coming back up or “repeating” into the mouth
  • Bitter or sour taste
  • Belching or bloating
  • Having a hard time swallowing
  • Heartburn
  • Passing black stools or vomiting blood, which may indicate gastrointestinal bleeding
  • Shortness of breath

Causes & Risk Factors

Weakened muscles that allow the stomach to protrude through the diaphragm lead to hiatal hernias, but it’s not always clear why this happens.

People who smoke, are older, are obese or are pregnant are at greater risk for hiatal hernias.

A hiatal hernia may be caused by:
  • Trauma, surgery or injury to the area
  • Birth defects or being born with a large hiatus (opening between the esophagus and stomach)
  • Persistent coughing, straining, vomiting, exercising or lifting heavy objects
  • A condition that puts pressure on the surrounding muscles, such as abdominal fluid buildup, pregnancy or obesity
  • Changes to the diaphragm caused by age

Diagnosis

Most people with hiatal hernias receive a diagnosis when they seek treatment for acid reflux, GERD, abdominal pain or chest pain. Imaging tests are the most common way to diagnose hiatal hernias.

Tests to diagnose hiatal hernias include:
  • Barium Swallow: A doctor will take an X-ray of the upper digestive system after the patient drinks a liquid that fills and coats the digestive tract. This test can show the size of the hernia and if the stomach is twisted.
  • Endoscopy: A doctor will insert a thin, flexible tube with a light at the end of it through the throat to examine the esophagus and stomach.
  • Esophageal Manometry: This is a swallowing test that measures the esophagus muscle’s coordination and strength.
  • pH Test: This test measures esophagus acid levels.
  • Gastric Emptying Studies: These studies allow doctors to see how fast food leaves the stomach.

Treatment

These hernias aren’t usually serious, and people with no symptoms or problems don’t require treatment. Patients can manage mild symptoms with lifestyle changes or acid reducing medications. More serious hernias may need surgery to repair.

In most cases, hiatal hernias aren’t medical emergencies. But hernias that become strangulated require emergency surgery. Strangulation can result in “necrosis (tissue death) or perforation of the stomach (a hole in the stomach tissue),” according to Carrott.

Medications for Symptoms

In some cases, acid-reducing medication can manage hiatal hernia symptoms. These include antacids such as Tums, H2 blockers and proton pump inhibitors.

H2 Blockers

H2 blockers include drugs such as Pepcid (famotidine) and Zantac (ranitidine). In April 2020, the FDA requested manufacturers withdraw all ranitidine products from the market because of cancer concerns. In 2021, a new Zantac formula made with famotidine returned to the market.

Proton Pump Inhibitors

Proton pump inhibitors, or PPIs, are another type of drug that helps reduce stomach acid. These include Nexium (esomeprazole), Prilosec (omeprazole) and Protonix (pantoprazole).

Surgical Hiatal Hernia Repair with Mesh

Hiatal hernia repair surgery is a relatively safe but complex operation that requires general anesthesia.

Surgeons most often repair hiatal hernias with synthetic mesh. Some doctors may decide to use sutures or native tissue to repair the hernia, but studies have shown synthetic mesh helps prevent the hernia from coming back.

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About 20 percent of patients experience changes in bowel habits after hiatal hernia surgery, most commonly diarrhea.

If the hernia is smaller, surgeons can use minimally invasive laparoscopic surgery to repair the hiatal hernia. The doctor makes several tiny incisions and inserts tools through the small holes. This makes recovery quicker because there is less blood loss and scarring. But if the hernia is very large, doctors may need to switch to open repair.

Some complications occur right after surgery, but others may occur months or even years later.

Hiatal hernia surgery complications include:
  • Bleeding
  • Infection
  • Injury to internal organs
  • Hernia recurrence
  • Excess gas
  • Delayed stomach emptying
  • Esophageal narrowing
  • Injury to the heart
  • Perforation of the esophagus and stomach
  • Difficulty swallowing
  • Diarrhea
  • Mesh erosion
  • Abnormal connection between organs (fistulas)

Mesh Complications

Mesh made of polypropylene plastic is the gold standard of care for most hernias.

But some studies have shown synthetic mesh used at the hiatus can cause rare but serious medical problems and the need for reoperation, according to a 2020 review article by Drs. Colette S. Inaba and Brant K. Oelschlager published in Annals of Laparoscopic and Endoscopic Surgery.

Complications arising from mesh used in hiatal hernia repairs, include: Mesh erosion, narrowing of the esophagus (esophageal stenosis) and large amounts of scar tissue.

Lawsuit Information
Learn more about lawsuits filed by patients who experienced serious complications after hernia mesh repair surgery.
View Lawsuits

Recovery After Surgery

Hiatal hernia surgery is a major operation. It can take weeks to months to fully recover from hernia surgery. Patients who have minimally invasive surgery may be able to return to work within two weeks.

Patients typically manage pain with prescription or over-the-counter pain relievers for the first few days. Immediately after surgery and for the first few days, patients should remain on a liquid diet and can add creamy or soft foods as instructed by the surgeon.

Swelling from the esophagus might make it difficult to swallow solid food. This can last up to eight weeks after the operation. Bowel changes include constipation and diarrhea.

If you suffer any severe pain, fever, redness at the surgical site, severe swallowing problems or inability to pass gas or stool, talk to your surgeon right away.

Please seek the advice of a medical professional before making health care decisions.