Hiatus (hiatal) hernia: symptoms, reflux and treatment

The stomach normally sits below the diaphragm, the sheet of muscle that separates the chest from the abdomen. In a hiatus hernia, part of the stomach moves up through that opening into the chest. Among the hernia types listed by the NHS it is the one that occurs in the chest, as opposed to the groin or belly button.

Because it can sit quietly, many hiatus hernias are never diagnosed. It is the reflux symptoms that tend to send people to the pharmacy or GP.

The NHS lists the symptoms of a hiatus hernia as a painful burning feeling in the chest, often after eating (heartburn), bringing up small amounts of food or bitter-tasting fluids (acid reflux), bad breath, feeling bloated, feeling or being sick, and difficulty or pain when swallowing (dysphagia). It notes that these are the symptoms of gastro-oesophageal reflux disease (GORD).

The NHS heartburn page adds that symptoms are often worse after eating, when lying down and when bending over, and lists a hiatus hernia, a stomach ulcer and a stomach infection among the things that can cause or worsen reflux, along with certain foods and drinks, being overweight, smoking, pregnancy, stress and some medicines such as anti-inflammatory painkillers.

The measures the NHS lists for a hiatus hernia are practical and low-risk.

• Eat smaller, more frequent meals.

• Raise the head end of your bed by 10 to 20cm so your chest and head are above the level of your waist. The NHS heartburn page says to use wood, bricks or books under the bed rather than extra pillows, which can raise pressure on the belly and worsen symptoms.

• Lose weight if you are overweight, and find ways to relax.

• Avoid food and drink that trigger symptoms, and do not eat within 3 or 4 hours of going to bed.

• Avoid clothes that are tight around your waist, do not smoke, and do not drink too much alcohol.

• Do not stop prescribed medicines without speaking to a doctor first.

A pharmacist may recommend antacids or alginates, taken with food or soon after eating when you are most likely to get symptoms. The NHS says these help in the short term but will not cure the problem and should not be taken regularly for long periods.

If pharmacy medicines and changes to eating habits do not help, a GP can prescribe stronger medicines. The NHS heartburn page names proton pump inhibitors such as omeprazole and lansoprazole, usually taken for 4 or 8 weeks depending on severity, and says to return to the GP if symptoms come back after stopping. If a PPI does not help, a different medicine type, an H2 receptor antagonist such as famotidine, may be tried.

If stronger medicines do not work, the NHS says a GP can arrange tests to find out whether a hiatus hernia is causing the symptoms, and may refer you to a specialist to check whether you need surgery. The heartburn page gives gastroscopy, where a thin tube with a camera is passed down the throat into the stomach, as an example of the tests for severe reflux, along with testing for stomach bacteria.

Surgery usually happens only when other treatments have not worked and symptoms remain very bad. The NHS says keyhole surgery is usually used, under general anaesthetic. It can take up to 6 weeks before you can eat what you want, and a few months to recover from bloating, wind and difficulty swallowing. There is a chance you may need more surgery.

The NHS advises seeing a GP if symptoms do not go away after 3 weeks, are very bad or getting worse, or pharmacy medicines do not help. Ask for an urgent GP appointment or contact NHS 111 if you have indigestion or reflux with unintentional weight loss, difficulty swallowing, frequent vomiting, blood in your vomit or upper tummy pain.

Chest pain that spreads to the arm, jaw or back, breathlessness or sweating should be treated as a possible heart problem, and 999 is the right call.