OVERVIEW

What is a Hiatal Hernia?

A hernia refers to a condition where part of a hollow organ, such as the stomach or intestines, protrudes into an area where it does not belong. A hiatal hernia is one such type. The term "hiatal" does not mean the esophagus is torn; rather, there is a thin layer of muscle between the chest and abdominal cavities called the diaphragm. The esophagus passes through the diaphragm to enter the abdominal cavity, and the opening through which it passes is called the "hiatus."
If a person's diaphragm is weak or abdominal pressure increases (e.g., due to obesity), the stomach or intestines (primarily the stomach, as intestinal protrusion is rare) that should remain in the abdomen may push through the "hiatus" into the chest cavity, resulting in a hiatal hernia.
The main impact of a hiatal hernia on the body is an increased likelihood of "gastroesophageal reflux." The esophageal hiatus in the diaphragm not only allows the esophagus to pass through but also helps prevent stomach acid from flowing back into the esophagus. When a hiatal hernia occurs, the diaphragm can no longer effectively prevent reflux. As a result, the likelihood of reflux increases, and patients may experience discomfort such as heartburn or acid regurgitation.

SYMPTOMS

How is hiatal hernia classified?

Clinically, hiatal hernias are commonly divided into 4 types:
Type I: Sliding hiatal hernia, where the gastroesophageal junction moves above the diaphragm, but the stomach retains its normal shape. This type accounts for 95% of hiatal hernias in China;
Type II: Paraesophageal hernia, where the gastroesophageal junction remains in its normal anatomical position, but part of the stomach herniates into the chest through the diaphragmatic hiatus beside the esophagus;
Type III: A combination of the first two types, with both the gastroesophageal junction and the gastric fundus located above the diaphragm;
Type IV: In addition to the stomach, other abdominal organs also enter the chest cavity.

Symptoms vary depending on the type.

Can hiatal hernia turn into cancer?

Hiatal hernia occurs when the stomach or intestines protrude into the chest cavity through the diaphragmatic esophageal opening. It is a structural change and does not lead to cancer. However, hiatal hernia can cause many complications, such as reflux esophagitis. If left untreated for a long time, it may increase the risk of esophageal cancer.

What are the symptoms of hiatal hernia?

Most patients with hiatal hernia experience no symptoms.
In symptomatic patients, the most common symptoms include acid reflux, heartburn, chest pain, abdominal pain, or discomfort. These are often caused by the loosening of the gastroesophageal junction, allowing stomach acid to flow back into the esophagus. These symptoms usually occur after overeating or drinking alcohol and may worsen depending on body position (standing typically alleviates symptoms compared to lying down).
Severe cases may also present with difficulty swallowing, shortness of breath, or palpitations.

Does acid reflux or heartburn mean I have a hiatal hernia?

Not necessarily. Many stomach and esophageal conditions can cause acid reflux and heartburn, with hiatal hernia accounting for only a small fraction.
If you experience acid reflux or heartburn, it is best to consult a gastroenterologist promptly to determine the cause and receive timely treatment.

Why do some hiatal hernia patients experience difficulty breathing or palpitations?

Severe cases may exhibit these symptoms. The esophagus occupies very little space in the chest cavity. When a hiatal hernia occurs, the stomach or intestines enter the chest. If the herniated organs are large, they can compress the lungs and heart, impairing their normal function and leading to symptoms like difficulty breathing and palpitations.

CAUSES

What causes a hiatal hernia?

A hiatal hernia occurs when the stomach or intestines protrude through the esophageal hiatus in the diaphragm. There are two main causes for the formation of a hiatal hernia:

• Congenital factors: For example, the diaphragm is inherently weak.
• Acquired factors: Increased abdominal pressure pushes the stomach or intestines upward, such as obesity, pregnancy, ascites, or chronic constipation.

Who is more likely to develop a hiatal hernia?

Current statistics show that women, obese individuals, and elderly people over 50 are more prone to hiatal hernias.
Patients with frequent coughing, ascites, or severe vomiting are also at higher risk.

Is a hiatal hernia hereditary?

Most hiatal hernias are acquired and rarely related to genetics. The majority of hiatal hernias are not hereditary.

Is a hiatal hernia contagious?

A hiatal hernia is caused by changes in the anatomical structure of the esophagus, diaphragm, and stomach. It is not caused by viruses or bacteria and therefore is not contagious.

DIAGNOSIS

How is hiatal hernia diagnosed?

It is usually diagnosed through barium meal fluoroscopy or gastroscopy. Some patients may also require esophageal pH monitoring to check whether the esophagus is affected or if gastric fluid is refluxing into the esophagus, which helps guide treatment.

What diseases resemble hiatal hernia?

Gastric conditions (chronic gastritis, gastric ulcers), heart diseases (angina, myocardial infarction), and biliary tract disorders (cholecystitis, gallstones) may cause symptoms similar to hiatal hernia, but their treatments differ significantly. Therefore, if experiencing acid reflux, heartburn, or palpitations, prompt medical consultation and diagnostic tests are essential to identify the cause and ensure appropriate treatment.

TREATMENT

When should someone with a hiatal hernia seek immediate medical attention?

Patients diagnosed with a hiatal hernia should seek immediate medical care if they experience severe chest or abdominal pain accompanied by nausea, vomiting, or the inability to pass gas or stool. These symptoms may indicate ischemia, necrosis of the stomach or intestines that have herniated into the chest cavity, or severe obstruction due to impaired gastrointestinal motility. Delayed treatment can be life-threatening.

Which department should hiatal hernia patients visit?

Generally, patients with a hiatal hernia can consult the gastroenterology department. Doctors typically diagnose the condition through endoscopy or barium swallow tests and provide treatment based on symptoms. Patients requiring surgery may be referred to the thoracic or general surgery department.

How is a hiatal hernia treated?

• Asymptomatic patients may not require treatment.
• Medication: Proton pump inhibitors (e.g., omeprazole, esomeprazole) are commonly prescribed to manage symptoms at the lowest effective dose.
• Surgery: Patients meeting surgical criteria may undergo corrective procedures.

How should GERD caused by a hiatal hernia be treated?

In addition to specific hiatal hernia management, GERD treatment includes lifestyle adjustments and medication:

• Consume easily digestible soft foods.
• Avoid spicy, high-fat, and reflux-triggering foods like coffee.
• Refrain from eating 2–3 hours before bedtime.
• Lose weight if obese.
• Elevate the bedhead by 15–20 cm to prevent aspiration pneumonia.
• Use reflux-aggravating medications cautiously under medical supervision.
• Medications: Acid suppressants (e.g., omeprazole, esomeprazole, cimetidine), antacids (e.g., Gaviscon), and prokinetics (e.g., domperidone) are commonly used.

Can a hiatal hernia be cured?

While a hiatal hernia cannot be fully cured, lifestyle changes, medications, or surgery can effectively manage symptoms and maintain quality of life.

When does a hiatal hernia require surgical intervention?

Surgery is recommended for:

• Failed medical treatment.
• Symptomatic paraesophageal hernias (where the stomach herniates beside the esophagus).
• Upper GI bleeding (e.g., hematemesis, melena).
• Acute gastric volvulus (twisting causing obstruction/ischemia).
• Obstructive symptoms (e.g., severe chest/abdominal pain).
• Suspected malignancy (chronic reflux may increase esophageal cancer risk).

Is surgery always effective for hiatal hernia?

Surgical goals include:

• Repositioning herniated organs and reinforcing the hiatus to prevent recurrence.
• Preventing acid reflux.

Success rates vary (50–90%), with complete failure rates around 5%. Surgery remains effective when necessary.

Can a hiatal hernia recur after surgery?

Recurrence occurs in ~10% of cases, with some patients requiring repeat surgery.

DIET & LIFESTYLE

What lifestyle precautions should patients with hiatal hernia take?

Lifestyle modifications can greatly benefit the relief of hiatal hernia. The following lifestyle adjustments are recommended:

• Adopt a diet of smaller, more frequent meals, avoid consuming large amounts of food at once, refrain from lying down immediately after eating, and try to avoid eating before bedtime;

• Actively treat or alleviate factors that increase abdominal pressure, such as chronic coughing or constipation, and avoid behaviors like wearing tight clothing that may raise abdominal pressure;

• Lose weight through reasonable methods like diet and exercise—this is particularly crucial for obese patients.

• Elevate the head of the bed by 15–20 cm while sleeping.

PREVENTION

Can hiatal hernia be prevented?

Congenital factors like a weak diaphragm are difficult to change; therefore, prevention of hiatal hernia mainly involves avoiding factors that increase abdominal pressure, such as actively treating coughs, using medication to reduce constipation, and for obese individuals, weight loss is also important.