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Health condition · Clinically reviewed

Hiatus hernia, from sliding reflux to paraoesophageal repair.

Up to a third of UK adults have some form of hiatus hernia. Most are managed medically. A smaller group needs specialist upper GI surgery, and the trick is telling them apart.

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Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, BSG and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK guidance on sliding and paraoesophageal hernias, PPI therapy and laparoscopic repair.

Key facts

Hiatus hernia at a glance.

The essentials, in plain English: what it is, the four anatomical types and how each is treated in the UK today.

  • What it is

    Herniation of intra-abdominal contents through the oesophageal hiatus of the diaphragm - most often the stomach.

  • How common

    Very common. Up to 30 per cent of adults have some form of hiatus hernia, rising with age and body-mass index.

  • Type I - sliding

    About 95 per cent of cases. The gastro-oesophageal junction slides above the diaphragm and reflux is the main problem.

  • Type II - paraoesophageal

    Junction stays below, but the fundus herniates alongside the oesophagus - risk of strangulation.

  • Types III and IV

    Mixed patterns and, rarely, herniation of colon, small bowel or omentum through the hiatus - a surgical concern.

  • Foundation therapy

    Lifestyle plus a proton-pump inhibitor for sliding hernias. Surgical repair for symptomatic paraoesophageal disease.

Why this guide matters

Common, mostly manageable - but not always trivial.

Three principles run through everything on this page: know the type, treat the reflux, and act early when a paraoesophageal hernia becomes symptomatic.

  • Type matters more than size

    A small paraoesophageal hernia can strangulate; a large sliding hernia may cause nothing but heartburn. Anatomy drives the plan.

  • Medical first for sliding

    Lifestyle plus a proton-pump inhibitor controls symptoms for the great majority of Type I sliding hernias.

  • Refer paraoesophageal early

    Symptomatic Type II to IV hernias are best repaired electively by a specialist upper GI surgeon - not after an emergency.

How the diagnosis is made

From first symptoms to a clear plan.

The steps a UK GP or upper GI specialist will normally follow, in order, so you know what to expect and why each test is done.

  1. 01

    Assessing

    History and risk factors

    Heartburn, regurgitation, dysphagia, postprandial fullness, chest pain. Obesity, pregnancy, age and heavy lifting all raise risk.

  2. 02

    Assessing

    Focused examination

    Usually unremarkable. Signs of anaemia or weight loss point towards Cameron ulcers or a more complex hernia.

  3. 03

    Assessing

    Upper GI endoscopy

    A gastroscopy confirms the hernia, grades reflux oesophagitis and rules out Barrett's or malignancy.

  4. 04

    Confirming

    Barium swallow

    Contrast studies map the anatomy of larger or paraoesophageal hernias and show how the stomach sits above the diaphragm.

  5. 05

    Confirming

    Manometry and pH studies

    Oesophageal manometry and 24-hour pH testing quantify motility and acid exposure before considering surgery.

  6. 06

    Confirming

    CT abdomen where needed

    A CT scan is used for large paraoesophageal hernias and to assess for strangulation or gastric volvulus.

  7. 07

    Planning

    Specialist upper GI MDT

    Complex or paraoesophageal hernias are discussed at a specialist commissioned upper GI multidisciplinary meeting before repair.

Typical timeline: from first consultation to a settled plan in a few weeks.

Symptoms

What a hiatus hernia actually feels like.

Many are silent. When symptoms appear, they usually come from reflux, from the mass effect of a large paraoesophageal hernia, or from complications - and each has its own pattern.

  • Heartburn

    Retrosternal burning after meals or when lying flat - the commonest symptom of a sliding hernia driving reflux.

  • Regurgitation

    Effortless return of gastric contents into the throat, often sour or bitter, worse at night.

  • Dysphagia

    Sensation of food sticking - can occur with larger hernias, reflux stricture or coexisting motility problems.

  • Postprandial fullness

    Early satiety and bloating after meals - typical of paraoesophageal hernias where the stomach sits in the chest.

  • Chest pain

    Central or retrosternal discomfort that can mimic cardiac pain. Always excluded before attributing to a hernia.

  • Iron-deficiency anaemia

    Cameron ulcers on the herniated stomach can bleed slowly and present as unexplained anaemia.

  • Belching and hiccups

    Aerophagia and reflex hiccups are common in larger hernias and settle after successful repair.

  • Red flag - acute chest pain

    Sudden severe chest or upper abdominal pain with vomiting can signal gastric volvulus or strangulation - a surgical emergency.

Treatment

How hiatus hernia is treated in the UK.

Lifestyle and PPI therapy for sliding hernias. Laparoscopic repair with fundoplication for symptomatic paraoesophageal disease. Emergency surgery for strangulation.

  • Lifestyle measures

    Weight loss, smaller meals, avoiding late eating, head-of-bed elevation and reducing alcohol and caffeine all reduce reflux from a sliding hernia.

  • Proton-pump inhibitor

    A PPI is the foundation of medical therapy for sliding hernias with GORD. Reviewed for step-down after symptom control.

  • H2 receptor antagonist

    An alternative or add-on to PPI, useful for breakthrough nocturnal symptoms in stable sliding disease.

  • Alginate therapy

    Raft-forming agents such as Gaviscon give quick, targeted relief of postprandial regurgitation alongside a PPI.

  • Anti-reflux surgery

    Nissen fundoplication is considered when medical therapy fails, side effects are intolerable, or reflux is complicated by strictures or Barrett's.

  • Paraoesophageal repair

    Symptomatic Type II to IV hernias are repaired laparoscopically by a specialist upper GI surgeon, usually with a fundoplication to prevent postoperative reflux.

  • Watchful waiting

    Small, asymptomatic sliding hernias need no treatment - reviewed only if symptoms change.

  • Emergency surgery

    Strangulation, obstruction or gastric volvulus requires urgent laparotomy or laparoscopy in a specialist centre.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or upper GI specialist knows your history and can tell you which parts of this guide apply. If in doubt, get seen.

  • NICE. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (CG184).

  • British Society of Gastroenterology (BSG). Guidelines on the management of hiatus hernia and reflux disease.

  • Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for the management of hiatal hernia.

  • NHS England. Specialised commissioning for complex upper gastrointestinal surgery.

Red flags

When a hiatus hernia needs urgent attention.

Most sliding hernias are safely managed in primary care. These are the situations that need faster escalation, and sometimes emergency surgery.

  • Gastric volvulus

    Sudden severe epigastric or chest pain with retching and inability to vomit or pass a nasogastric tube - Borchardt's triad. A surgical emergency.

  • Strangulation

    Ischaemia of the herniated stomach causes constant pain, tachycardia and systemic upset. Requires urgent laparotomy.

  • Haematemesis or melaena

    Overt upper gastrointestinal bleeding, including from Cameron ulcers, needs urgent endoscopy and admission.

  • Progressive dysphagia

    Worsening difficulty swallowing, especially with weight loss, must be investigated urgently to exclude oesophageal cancer or a tight stricture.

  • Unexplained weight loss

    Any unintentional weight loss with reflux symptoms warrants urgent gastroscopy on a suspected cancer pathway.

  • Iron-deficiency anaemia

    Especially in men or postmenopausal women, warrants dual endoscopy to exclude Cameron ulcers and other bleeding sources.

  • Refractory reflux

    Symptoms persisting despite full-dose PPI need reassessment - a large hernia or a motility disorder may be the cause.

  • Barrett's oesophagus

    Long-segment reflux disease and hernia raise the risk of Barrett's. Surveillance endoscopy follows BSG criteria.

  • Recurrent aspiration

    Nocturnal cough, hoarseness or aspiration pneumonia in a patient with a large hernia is a signal to escalate management.

Living with it

A treatable condition, with a clear ladder.

Four practical levers make the biggest difference day to day: how you eat, what you weigh, how you sleep, and when to press for a specialist opinion.

A quiet reminder

Small changes, kept up, beat heroic ones that lapse.

Reflux responds to habit as much as to tablets. A calmer eating pattern is often the difference between symptomatic and settled.

  1. 01 Meals

    Eat smaller, earlier

    Smaller portions, an evening meal at least three hours before bed, and staying upright afterwards ease reflux from a sliding hernia.

  2. 02 Weight

    Weight is the biggest lever

    Even modest weight loss reduces intra-abdominal pressure and reflux - often more effective than any single medication.

  3. 03 Position

    Raise the head of the bed

    A wedge pillow or bed blocks - not just extra pillows - reduce nocturnal acid exposure. Comfortable, cheap and evidence-based.

  4. 04 Escalate

    Know when to ask for surgery

    Persistent symptoms on full-dose PPI, or any paraoesophageal hernia with symptoms, deserves a specialist upper GI opinion.

Frequently asked

Everything we get asked about hiatus hernia.

Quick answers on the types, when surgery is needed, and how it links to reflux disease.

  • What is a hiatus hernia?

    A hiatus hernia occurs when part of the stomach - and occasionally other organs - moves up through the oesophageal hiatus of the diaphragm into the chest. Most are sliding hernias linked with acid reflux; a smaller group are paraoesophageal and carry a risk of strangulation.

  • Do all hiatus hernias need treatment?

    No. Small, asymptomatic sliding hernias need nothing more than reassurance. Symptomatic sliding hernias are managed as reflux disease with lifestyle changes and a proton-pump inhibitor. Symptomatic paraoesophageal hernias usually warrant surgical repair even when symptoms are mild.

  • What is the difference between a sliding and paraoesophageal hernia?

    In a sliding (Type I) hernia the gastro-oesophageal junction and part of the fundus slide up through the diaphragm. In a paraoesophageal (Type II) hernia the junction stays put but the fundus herniates alongside it. Types III and IV are mixed and can involve other organs such as colon or small bowel.

  • When is surgery for a hiatus hernia recommended?

    Surgery is considered for reflux that fails to respond to full-dose medical therapy, for intolerable side effects, for large paraoesophageal hernias with symptoms, and urgently for strangulation, volvulus or obstruction. Repair is typically laparoscopic with a fundoplication to control reflux.

  • Can a hiatus hernia cause chest pain?

    Yes. A large hernia can produce retrosternal or epigastric pain, especially after meals. Cardiac causes must always be excluded first. Sudden severe chest pain with retching is a red flag for gastric volvulus and needs emergency assessment.

  • Are hiatus hernias linked to any other conditions?

    They are strongly linked to gastro-oesophageal reflux disease and its complications, including oesophagitis, strictures and Barrett's oesophagus. Connective-tissue disorders such as Ehlers-Danlos syndrome, obesity and pregnancy all increase risk.

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