A hiatal hernia is a condition where part of your stomach pushes up through the opening in your diaphragm (called the hiatus) that your esophagus normally passes through. The diaphragm is the large muscle separating your chest from your abdomen, and it has a small hole where the esophagus connects to the stomach. When that hole weakens or stretches, the upper part of the stomach can slide upward into the chest cavity, disrupting the normal barrier that keeps food and acid flowing in the right direction.
How the Esophagus and Diaphragm Work Together
Your body has a two-part system to prevent stomach acid from flowing backward into the esophagus. The first part is a ring of muscle at the bottom of the esophagus that opens to let food into the stomach and closes afterward. The second part is the diaphragm itself, which wraps around the esophagus at the hiatus and acts like an external clamp. These two components normally sit at the same level and work in concert to keep acid where it belongs.
When a hiatal hernia develops, the stomach slides upward and separates these two protective structures. The muscular ring at the bottom of the esophagus gets pulled up into the chest, while the diaphragm stays in place. This spatial gap between them weakens the anti-reflux barrier, making it far easier for acid and food to travel back up into the esophagus.
Types of Hiatal Hernia
There are four recognized types, but the vast majority of people have one kind.
- Type 1 (sliding): The junction between the esophagus and stomach slides upward through the hiatus. This accounts for roughly 95% of all hiatal hernias and is the type most associated with acid reflux.
- Type 2 (paraesophageal): The esophagus-stomach junction stays in its normal position, but a portion of the stomach bulges up beside the esophagus into the chest cavity. This type is less common but carries more risk of complications.
- Type 3 (mixed): A combination of both. The junction is displaced into the chest along with a large portion of the stomach, which may be abnormally rotated.
- Type 4: Similar to Type 3, but other abdominal organs (such as the colon or spleen) also push through the hiatus alongside the stomach.
Types 2 through 4 together make up fewer than 10% of cases.
Who Gets Hiatal Hernias
Hiatal hernias become significantly more common with age. A large study tracking over 3,200 adults (aged 53 to 94) using CT imaging found that prevalence climbed steadily by decade: about 2.4% of people in their 50s had one, rising to 7% in their 60s, 14% in their 70s, and 16.6% in their 80s and beyond. This increase likely reflects the gradual weakening and stretching of the diaphragm’s hiatus over a lifetime, compounded by changes in connective tissue and increased abdominal pressure from weight gain.
Other contributing factors include pregnancy, repeated heavy lifting, chronic coughing, and obesity. Some people are born with a larger-than-normal hiatus, which makes them more susceptible from the start.
Symptoms and When They Appear
Most small hiatal hernias cause no symptoms at all. Many people have one and never know it, often discovering it incidentally during imaging for something else. Larger hernias, however, can produce a range of problems:
- Heartburn: A burning sensation in the chest, typically worse after eating or lying down.
- Regurgitation: Food or liquid flowing back into the mouth or throat.
- Difficulty swallowing: A sensation of food getting stuck on the way down.
- Chest or upper abdominal pain.
- Feeling full quickly after eating only a small amount.
- Shortness of breath, particularly with larger hernias that compress the lungs.
In rare cases, a hiatal hernia can cause slow bleeding in the digestive tract, which shows up as vomiting blood or passing dark, tarry stools.
Hiatal Hernia Chest Pain vs. Heart Problems
One of the most unsettling aspects of a hiatal hernia is that its chest pain can feel very similar to a heart attack. Even experienced doctors sometimes can’t distinguish between the two based on symptoms alone. That said, there are patterns that help tell them apart.
Heartburn from a hiatal hernia tends to produce a burning sensation in the chest and upper abdomen. It usually happens after eating, while lying down, or while bending over. Antacids typically bring relief, and you may notice a sour taste in your mouth or small amounts of food rising into the back of your throat.
Heart-related chest pain more often feels like pressure, tightness, or squeezing that may spread to the neck, jaw, or arms. It can come with cold sweat, sudden dizziness, fatigue, or nausea. If you experience these symptoms, especially during physical exertion, treat it as a potential cardiac emergency.
How Hiatal Hernias Are Diagnosed
Three tests are commonly used. A barium swallow involves drinking a chalky liquid that coats your esophagus and stomach, then taking X-rays. The coating creates a visible outline of your upper digestive tract, revealing whether part of the stomach has moved above the diaphragm.
An upper endoscopy uses a thin, flexible tube with a tiny camera threaded down your throat. It gives a direct view of the esophagus and stomach lining, allowing your doctor to check for inflammation, ulcers, or narrowing caused by chronic acid exposure.
Esophageal manometry measures the strength and coordination of muscle contractions in your esophagus as you swallow. It helps evaluate how well the muscular ring at the bottom of the esophagus is functioning and can identify problems that overlap with hernia symptoms.
Lifestyle Changes That Help
For many people with a hiatal hernia, symptoms can be managed without medication or surgery. Eating smaller meals every few hours instead of three large ones reduces the pressure that pushes stomach contents upward. Avoid eating within two to three hours of bedtime, since lying flat makes reflux worse.
Elevating the head of your bed so your chest sits higher than your legs helps gravity keep acid in the stomach overnight. This means raising the actual bed frame or using a wedge pillow, not just stacking regular pillows (which can bend your body in a way that increases abdominal pressure). Reaching and maintaining a healthy weight also reduces strain on the hiatus, as excess abdominal fat pushes the stomach upward.
Common food triggers include spicy or fatty foods, citrus, tomato-based dishes, chocolate, caffeine, and alcohol. Keeping track of which specific foods worsen your symptoms is more useful than following a generic restriction list.
Medical Treatment
When lifestyle changes aren’t enough, acid-reducing medications are the standard next step. Over-the-counter antacids can provide quick, short-term relief. For more persistent symptoms, proton pump inhibitors (PPIs) reduce the amount of acid your stomach produces. These are taken once daily and are widely available both over the counter and by prescription. H2 blockers are another option that work through a slightly different mechanism to lower acid production.
These medications don’t fix the hernia itself. They manage symptoms by reducing the damage that acid does when it refluxes into the esophagus.
When Surgery Becomes Necessary
Surgery is typically reserved for people whose symptoms don’t respond to medication, or who have a paraesophageal hernia (Types 2 through 4) that poses a risk of complications. The most common procedure is called fundoplication, where the surgeon wraps the upper part of the stomach around the lower esophagus to reinforce the anti-reflux barrier. If a hernia is present, it’s repaired at the same time by tightening the hiatus.
This surgery is usually done laparoscopically through small incisions. About 90% of patients don’t need further surgery afterward, though roughly 10% eventually require a second procedure.
Dangerous Complications
Paraesophageal hernias carry a specific risk that sliding hernias do not. Because part of the stomach sits beside the esophagus in the chest, it can twist or rotate on itself. This is called a gastric volvulus, and it can cut off blood supply to the stomach (strangulation). Symptoms include sudden, severe abdominal or chest pain, inability to vomit despite the urge, and difficulty swallowing. This is a surgical emergency requiring immediate treatment to prevent tissue death.
While this complication is uncommon, it’s the primary reason doctors sometimes recommend elective surgery for larger paraesophageal hernias even when symptoms are mild.