What is a Hiatus Hernia?
Normally, the stomach sits completely below the diaphragm. The oesophagus (gullet) passes through an opening in the diaphragm (called the hiatus) to join the stomach just below it.
A hiatus hernia occurs when the upper portion of the stomach moves up into the chest through this opening in the diaphragm. It is a common condition, occurring in about one in ten individuals.
Types of Hiatus Hernia
- Sliding Hiatus Hernia: This is the most common type. It occurs when the junction between the oesophagus and stomach slides up into the chest.
- Rolling (Paraesophageal) Hiatus Hernia: In this type, the junction between the stomach and oesophagus remains in its normal position in the abdomen, but another part of the stomach moves into the chest through the diaphragm. This type has a higher risk of complications.
- Mixed Hiatus Hernia: A combination of the sliding and rolling types.
- Complex Hiatus Hernia: A severe form where other abdominal organs, such as the colon, spleen, or liver, also move into the chest.
What Causes a Hiatus Hernia?
The exact cause of a hiatus hernia is not fully understood, but several factors may increase the risk:
- Obesity
- Heavy lifting or frequent straining
- Smoking
- Certain medications (e.g., steroids)
- Connective tissue disorders
- Kyphosis (hunchback)
What Are the Symptoms of a Hiatus Hernia?
Many people with a hiatus hernia have no symptoms, and the condition is often discovered incidentally on imaging tests such as a barium X-ray, gastroscopy, or CT scan. However, when symptoms do occur, they may include:
- Symptoms of Acid Reflux (GORD): Heartburn and regurgitation caused by acidic stomach contents flowing back into the oesophagus. These symptoms are often worse when lying flat or bending over.
- Other Symptoms:
- Gurgling or bubbling sensations in the chest
- Severe chest pain that may mimic a heart attack
- Frequent hiccups and belching
- Shortness of breath
What Are the Complications of a Hiatus Hernia?
Most small hiatus hernias do not cause complications. However, in some cases, complications may arise:
- Acid Reflux-Related Complications: Chronic acid exposure can cause:
- Narrowing of the oesophagus (stricture)
- Recurrent chest infections
- Hoarse voice
- Acid damage to the teeth
- Barrett’s oesophagus (a precancerous condition)
- In rare cases, oesophageal cancer
- Stomach Ulcers and Bleeding: The diaphragm rubbing against the stomach wall can cause ulcers, leading to internal bleeding.
- Stomach Volvulus (Twisting): In large hernias, the stomach may twist within the chest, causing an obstruction.
- Strangulation: If blood flow to the stomach is cut off, the stomach tissue may die, requiring emergency surgery.
How is a Hiatus Hernia Treated?
For people with no symptoms, treatment is usually not required. Those with mild to moderate symptoms of acid reflux (GORD) are typically managed with lifestyle changes and medications.
When Should Surgery Be Considered?
Surgical treatment may be recommended in the following situations:
- Persistent GORD symptoms that do not respond to medication
- Severe reflux with “volume reflux” (large amounts of stomach contents reaching the mouth when bending over or lying flat)
- Complications such as strictures, Barrett’s oesophagus, or recurrent infections
- Large hiatus hernias causing pressure symptoms, such as chest pain, difficulty breathing, or a feeling of fullness in the chest
How is a Hiatus Hernia Repaired?
Surgery is typically performed using keyhole (laparoscopic) techniques. The procedure involves:
- Reducing the herniated stomach and hernia sac back into the abdomen
- Freeing the oesophagus inside the chest to allow proper repositioning
- Repairing the opening in the diaphragm (hiatus) with stitches, and sometimes reinforcing it with a mesh
- Performing a fundoplication, where the top part of the stomach is wrapped around the lower oesophagus to restore the one-way valve function
In some cases, an open surgical approach may be required, especially if there are significant adhesions from previous surgeries or if the stomach is fragile due to obstruction.
Key Takeaways
- A hiatus hernia occurs when part of the stomach moves into the chest through the diaphragm.
- Most cases are asymptomatic, but some people experience acid reflux, chest pain, or breathing difficulties.
- Small hernias without symptoms typically do not require treatment.
- For symptomatic cases, lifestyle changes, medications, or surgery may be recommended.
- Large or complex hernias may require surgical repair to prevent serious complications such as obstruction or strangulation.
