A stomach hernia, most commonly called a hiatal hernia, occurs when part of your stomach pushes upward through the diaphragm, the muscular wall separating your chest from your abdomen. It’s extremely common, becomes more prevalent with age, and in many cases causes no symptoms at all. When it does cause problems, the main issue is acid reflux.
How a Stomach Hernia Forms
Your diaphragm has a small opening called the hiatus, roughly 2 centimeters long, where the esophagus passes through on its way to your stomach. A band of connective tissue anchors the junction between your esophagus and stomach in place, keeping the stomach below the diaphragm where it belongs. When that connective tissue weakens or stretches, part of the stomach can slide upward through the opening and into the chest cavity.
The hiatus naturally narrows when pressure in your abdomen rises, like when you cough or lift something heavy. But over time, aging causes the surrounding muscle and tissue to lose elasticity. In older adults, the upper portion of the stomach may push through during a swallow and simply not slide back down. This is why hiatal hernias become increasingly common as people get older.
Types of Hiatal Hernia
There are three main types, and they differ in how the stomach moves through the diaphragm.
- Sliding hiatal hernia (Type I): The most common type by far, accounting for up to 99% of all hiatal hernias. The junction between the esophagus and stomach slides upward through the hiatus symmetrically. These are usually small and often cause no trouble.
- Paraesophageal hernia (Type II): A portion of the stomach pushes up alongside the esophagus into the chest, while the esophageal junction stays in its normal position. This type is less common but can lead to more serious complications.
- Mixed hernia (Type III): A combination of both, where the esophageal junction and a portion of the stomach both migrate upward into the chest.
A hernia is formally diagnosed when the gap between the esophageal junction and the diaphragm measures more than 2 centimeters.
Symptoms to Recognize
Many people with a hiatal hernia never experience symptoms and only discover it incidentally during imaging or an endoscopy for something else. When symptoms do appear, they’re almost always related to acid reflux (GERD) because the displaced stomach allows acid to flow back into the esophagus more easily.
The most common symptoms include heartburn, indigestion, feeling full soon after eating with a burning pain in the upper abdomen, burping, and food or acid rising into the throat. Some people notice difficulty swallowing or a lump-like sensation when they swallow. Acid irritation can also cause a sore throat and hoarseness.
Less obvious symptoms catch some people off guard. Chest pain that feels cardiac but isn’t is common enough to have its own name: noncardiac chest pain. Some people experience nausea from the stomach being compressed, or even shortness of breath if a larger hernia presses against the lungs.
How It’s Diagnosed
Most hiatal hernias are found during an upper endoscopy, where a thin camera is passed down your throat to examine the esophagus and stomach. A barium swallow, where you drink a chalky liquid and then get X-rayed, can also reveal the hernia by showing the stomach’s position relative to the diaphragm. In some cases, a pressure-measuring test of the esophagus can detect the separation. The most definitive confirmation comes during surgery, which serves as the gold standard for diagnosis.
Managing Symptoms Without Surgery
For most people, a hiatal hernia is managed with lifestyle changes and, if needed, acid-reducing medication. The goal is to control reflux symptoms rather than fix the hernia itself, since many hernias are small and harmless.
Acid-reducing medications called proton pump inhibitors are the standard treatment when reflux symptoms are persistent. These reduce the amount of acid your stomach produces, giving your esophagus a chance to heal from irritation. Most people start on a once-daily dose, and many can eventually step down to a lower dose or stop altogether once symptoms are controlled.
Lifestyle Changes That Help
Dietary adjustments can make a significant difference. Common triggers include citrus fruits and juices, chocolate, fatty and fried foods, garlic and onions, spicy food, tomato-based sauces, coffee and tea (even decaf), alcohol, and carbonated drinks. You don’t necessarily need to eliminate all of these, but identifying your personal triggers and reducing them helps considerably.
How you eat matters as much as what you eat. Smaller, more frequent meals put less pressure on the stomach than large ones. Eating slowly reduces the chance of triggering heartburn. Avoid lying down for at least three hours after a meal, and don’t bend over right after eating.
At night, raising the head of your bed 6 to 8 inches using wooden blocks or sturdy risers under the bedposts helps keep acid from flowing upward while you sleep. Simply propping your head up with extra pillows doesn’t work as well because it bends your body at the waist rather than tilting your entire torso.
When Surgery Becomes an Option
Surgery is typically reserved for people whose symptoms don’t improve with medication and lifestyle changes, or for those with larger paraesophageal hernias that carry a risk of complications. The most common procedure wraps the upper part of the stomach around the lower esophagus to reinforce the barrier against acid reflux and reposition the stomach below the diaphragm. It’s usually done laparoscopically through small incisions.
Outcomes are generally good, though about 10% of people who have the procedure eventually need a second operation. For large hernia repairs, imaging studies show that 20 to 30% of patients develop a recurrence on X-ray after surgery, but most of these recurrences are small and cause no symptoms. In one study following patients for up to five years after large hernia repair, over 94% of those with a recurrence still said their decision to have surgery was the right one, and only two out of 41 patients with a recurrent hernia needed a revision surgery. Heartburn scores and medication use were slightly higher in the recurrence group, but overall satisfaction remained high.
Serious Complications to Watch For
Most hiatal hernias are benign, but paraesophageal and mixed types carry a small risk of a dangerous complication called gastric volvulus, where the stomach twists on itself. This can cut off blood supply to part of the stomach, leading to tissue death and perforation. The warning signs are severe upper abdominal pain, retching without being able to vomit, and the feeling that something is seriously wrong. This is a medical emergency. Historically, acute gastric volvulus carried mortality rates of 30 to 50%, though advances in diagnosis and treatment have brought that down to 15 to 20%. Strangulation of the stomach has been reported in 5 to 28% of cases involving twisting.
These severe complications are rare, especially with the sliding type that makes up the vast majority of hiatal hernias. But if you experience sudden, intense abdominal pain with an inability to vomit, that warrants immediate emergency care.