Hiatus hernia: symptoms, treatment, diet and when surgery is needed

Many people with a hiatus hernia have no symptoms at all. The NHS says you can have one without knowing and without it being a problem. NHS inform makes the same point: the hernia itself rarely causes noticeable symptoms, but it can lead to gastro-oesophageal reflux disease (GORD), where stomach acid leaks into the oesophagus.

The NHS lists these symptoms, which it notes are the symptoms of GORD. NHS inform adds chest pain and an unpleasant sour taste in the mouth.

• A painful burning feeling in the chest, often after eating (heartburn).

• Bringing up small amounts of food or bitter-tasting fluid (acid reflux).

• Bad breath.

• Feeling bloated.

• Feeling or being sick.

• Difficulty or pain when swallowing (dysphagia).

• Chest pain and a sour taste in the mouth (NHS inform).

The diaphragm is a large, thin sheet of muscle between the chest and the abdomen. The oesophagus (the tube that carries food to the stomach) passes through a gap in it called the hiatus. In a hiatus hernia, NHS inform explains, part of the stomach squeezes up through that opening into the chest.

The NHS says it is not clear what causes a hiatus hernia. Anyone can have one, but it is more common if you are over 50, pregnant or overweight. NHS inform suggests it may result from the diaphragm weakening with age, or from pressure on the abdomen, and says that a rare type can affect newborn babies when the stomach or diaphragm does not develop properly.

NHS inform explains why reflux happens: a hiatus hernia can stop the valve at the bottom of the oesophagus working properly, leaving the oesophagus unprotected against stomach acid.

The NHS says a hiatus hernia does not normally need treatment if it is not causing you problems. NHS inform says treatment for the common sliding type usually focuses on relieving the symptoms of GORD: lifestyle changes and medication are the preferred treatments, and surgery is usually only an alternative to long-term medication or for when other treatments have not worked.

The NHS describes a stepped approach. First comes self-care and pharmacy medicines such as antacids or alginates. If these and changes to eating habits do not help, a GP can prescribe stronger medicines. If those do not work, a GP can arrange tests to find out whether your symptoms are caused by a hiatus hernia and may refer you to a specialist to check whether you need surgery.

There is no single hiatus hernia diet. The NHS and NHS inform give a practical list of things that help the reflux a hernia can cause, and the NHS says to avoid any food or drink that triggers your symptoms.

• Eat smaller, more frequent meals instead of three large meals a day.

• Do not eat within 3 or 4 hours of going to bed (NHS inform says to avoid lying down for at least 3 hours after eating or drinking).

• Raise the head end of the bed by around 10 to 20cm using blocks or bricks; NHS inform advises against extra pillows because they can increase pressure on the abdomen.

• Avoid foods and drinks that make symptoms worse. NHS inform gives examples: alcohol, caffeine, chocolate, tomatoes, fatty, spicy or acidic foods and drinks such as citrus juice.

• If you are overweight, losing weight may reduce the severity and frequency of symptoms.

• Do not smoke; NHS inform says tobacco smoke can irritate the digestive system.

• Avoid tight clothes around the waist and try to find ways to relax.

• Do not stop prescribed medicine without speaking to a doctor.

NHS inform describes four groups. Antacids neutralise stomach acid and come as liquid or tablets, but do not work for everyone and are not a long-term solution; they should not be taken at the same time as other medicines, because they can stop them being absorbed properly. Alginates form a protective coating over the stomach and oesophagus lining.

H2-receptor antagonists reduce the amount of acid the stomach produces by blocking histamine. Proton-pump inhibitors (PPIs), such as omeprazole, lansoprazole, rabeprazole and esomeprazole, also reduce acid production. NHS inform says most people tolerate PPIs well and that side effects, when they occur, are usually mild and can include headaches, diarrhoea, feeling sick or constipation.

Ask a pharmacist or GP which medicine is suitable for you. If you are pregnant, the NHS says a pharmacist can advise about the medicines you can take.

The NHS says surgery usually happens only if other treatments have not worked and you keep having very bad symptoms. It is usually keyhole surgery (laparoscopy) under general anaesthetic, using small cuts in the tummy. NHS inform says one of the most common techniques is laparoscopic Nissen fundoplication, in which the stomach is put back into position and the diaphragm around the lower oesophagus is tightened.

Before surgery you may need tests to check how well the oesophagus moves (manometry) and how much acid is refluxing (24-hour pH studies). NHS inform says the operation takes 60 to 90 minutes, that most people leave hospital within 2 to 3 days, and that you may return to work within 3 to 6 weeks depending on your job.

Recovery takes time. The NHS says 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, and that there is a chance of needing more surgery. NHS inform says these side effects usually settle over a few months but remain persistent in about 1 in 100 cases, and that for the first 6 weeks only soft food is recommended.

NHS inform describes two main types. They behave differently, which is why the advice on surgery differs.

NHS inform says a hiatus hernia can usually be diagnosed after a gastroscopy or a barium meal X-ray. In a gastroscopy a thin flexible tube with a light and camera is passed through the mouth and down the throat, with a local anaesthetic or sedative if needed. The NHS says a gastroscopy can be arranged to find the cause of symptoms such as indigestion, difficulty swallowing, stomach pain, black sticky poo or vomiting blood.

For a barium meal X-ray you drink a chalky barium liquid and a series of X-rays is taken. NHS inform says you cannot eat or drink for at least 6 hours beforehand, the test takes about 15 minutes, and the barium may cause constipation and white stools for a few days.

NHS inform says complications are rare but can be serious. Long-term damage to the oesophagus from leaking acid can lead to ulcers that may bleed, scarring that narrows the oesophagus (stricture), and cell changes known as Barrett's oesophagus, which can increase the risk of oesophageal cancer. It advises talking to your GP if you have persistent reflux symptoms for more than 3 weeks.

The NHS says to see a GP if symptoms do not go away after 3 weeks, are very bad or getting worse, or medicines from a pharmacy do not help. It says to ask for an urgent GP appointment or call NHS 111 if you have indigestion or acid reflux and you have lost weight without trying, swallowing becomes difficult, you are being sick frequently, there is blood in your sick or you have pain in your upper tummy.

NHS inform says a strangulated para-oesophageal hernia is an emergency that usually needs emergency surgery. If you have sudden severe chest or abdominal pain, call 999 or go to A&E. Chest pain can also have a heart cause, so do not assume it is the hernia.

On the NHS, care usually starts with a pharmacist or GP. A GP can prescribe stronger medicines and arrange tests or a specialist referral if these do not help. Gastroscopy and surgical repair are usually arranged in hospital following that referral.

You can also arrange a gastroscopy or a surgical opinion privately. The tests and operations are broadly the same, but ask who will review the results and what follow-up is included. In either setting, the first things to try are the same lifestyle measures and pharmacy medicines described above.