Causes
A hiatal hernia develops when the muscle tissue around the hiatus weakens or the opening enlarges. Contributing factors include:- Age-related changes: The diaphragm and its supporting tissues naturally lose elasticity over time.
- Increased pressure in the abdomen: Obesity, pregnancy, chronic coughing, repeated heavy lifting, and straining with constipation all push the stomach upward.
- Injury or surgery: Trauma to the area or prior operations can weaken the hiatus.
- Being born with a larger hiatus: Some people simply have a wider opening from birth.
Symptoms
Many hiatal hernias — particularly small ones — cause no symptoms and are found incidentally on imaging or endoscopy. When symptoms occur, they are usually those of acid reflux, because the hernia weakens the natural valve between the esophagus and stomach:- Heartburn: Burning discomfort behind the breastbone, often worse after meals or when lying down; frequent heartburn overlaps with gastroesophageal reflux disease (GERD).
- Regurgitation: Sour fluid or food coming back up into the throat or mouth.
- Throat symptoms: Hoarseness, throat clearing, or a lump-in-the-throat feeling, as seen in laryngopharyngeal reflux.
- Difficulty swallowing or early fullness: More common with larger hernias.
- Chest or upper abdominal discomfort: A large paraesophageal hernia can cause pressure-like pain after eating.
Diagnosis
A hiatal hernia may be identified on a barium swallow X-ray, an upper endoscopy, or a CT scan done for another reason. Endoscopy has the advantage of directly examining the esophagus and stomach lining, checking for irritation, gastritis, or ulcers. Esophageal manometry and pH testing are sometimes used when surgery is being considered or symptoms are hard to explain.Treatment
Treatment targets symptoms, not the hernia's mere presence.- Lifestyle measures: Smaller meals, avoiding food within three hours of bedtime, elevating the head of the bed, limiting trigger foods, losing excess weight, and stopping smoking.
- Acid-reducing medications: Proton pump inhibitors such as omeprazole, esomeprazole, or pantoprazole are the most effective medicines for reflux symptoms; H2 blockers such as famotidine help milder cases.
- Surgery: Reserved for large paraesophageal hernias or reflux that persists despite optimal medical therapy. Repair typically involves pulling the stomach back into the abdomen, tightening the hiatus, and often a fundoplication to reinforce the valve.