Health condition · Clinically reviewed
Hiatus hernia, sliding and paraoesophageal — and modern surgery.
Part of the stomach herniating up into the chest through the diaphragm. Sliding hiatus hernias cause reflux; paraoesophageal hiatus hernias can strangulate — a surgical emergency in that scenario.
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
Every claim is checked against NICE, BSG or peer-reviewed sources you can see at the end.
- 03
Current for 2026
Reflects current UK guidance on hiatus hernia — sliding vs paraoesophageal, and modern surgical repair.
Key facts
Hiatus hernia at a glance.
The essentials, in plain English — what a hiatus hernia is, how it is found, and how sliding and paraoesophageal types differ in management.
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What it is
Herniation of part of the stomach up through the diaphragmatic hiatus into the chest.
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Two main types
Sliding (type I, most common) versus paraoesophageal (types II-IV) — different behaviour, different management.
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How it is found
Often incidental on upper GI endoscopy or CT imaging done for other reasons.
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Sliding hernia
Managed as reflux — lifestyle, PPIs, and surgery only for selected patients.
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Large paraoesophageal
Surgical repair is often recommended because of the risk of strangulation and volvulus.
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Standard operation
Laparoscopic hiatal repair with fundoplication (Nissen or Toupet) is the mainstay.
Why this guide matters
Two different problems under one name.
A sliding hiatus hernia and a paraoesophageal hiatus hernia behave differently and are treated differently. The three points below shape everything else on this page.
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Sliding hernias are reflux
Lifestyle, PPIs and — for a small group — reflux surgery.
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Paraoesophageal hernias can strangulate
Large ones are often repaired to prevent volvulus and emergency surgery.
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Modern surgery is laparoscopic
Hiatal repair with fundoplication (Nissen or Toupet) is the mainstay.
How the diagnosis is made
From first symptoms to a clear plan.
The steps a UK GP and upper GI team will normally follow, in order — so you know what to expect and why.
Phase 1 · Recognising
Symptom pattern and first-line endoscopy
Phase 2 · Confirming
CT, manometry and pH studies where needed
Phase 3 · Managing
Surgical opinion and cardiac exclusion
- 01
Recognising
Symptom review
Reflux, regurgitation, chest discomfort, breathlessness or dysphagia — the pattern guides the workup.
- 02
Recognising
Upper GI endoscopy
The main test — confirms the hernia, measures it, and rules out oesophagitis, Barrett’s or malignancy.
- 03
Confirming
CT chest and upper abdomen
Defines the anatomy of a large paraoesophageal hernia and plans surgical repair.
- 04
Confirming
Oesophageal manometry
Requested if reflux surgery is being considered — checks motility before fundoplication.
- 05
Confirming
24-hour pH monitoring
Confirms acid reflux objectively when symptoms and endoscopy do not agree.
- 06
Managing
Upper GI surgery consultation
Specialist opinion for large paraoesophageal hernias or PPI-resistant sliding hernias.
- 07
Managing
Cardiology exclusion
Chest pain overlaps with cardiac disease — always exclude a heart cause before attributing pain to a hernia.
Typical timeline: weeks to a few months from first endoscopy to a settled plan.
Symptoms
What a hiatus hernia actually feels like.
Sliding hernias mostly present as reflux. Large paraoesophageal hernias can cause obstructive symptoms — and, rarely, an emergency.
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Reflux
Heartburn and acid regurgitation — the dominant symptom in sliding hernias.
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Dysphagia
A sense of food catching or slow passage — needs endoscopic assessment.
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Regurgitation
Undigested food or fluid returning to the throat, worse when bending or lying down.
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Breathlessness
A large hernia can compress the lung base — breathlessness after meals is a clue.
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Chest pain
Pressure or pain behind the breastbone — always rule out a cardiac cause first.
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Iron-deficiency anaemia
Slow bleeding from hernia-related erosions (Cameron lesions) can present as anaemia.
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Paraoesophageal symptoms
Obstructive symptoms — post-meal fullness, chest pressure, difficulty swallowing solids.
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Red flag
Sudden severe chest or abdominal pain with vomiting — call 999. This can be gastric volvulus.
Treatment
How hiatus hernia is treated in the UK.
Lifestyle and medication for sliding hernias; laparoscopic repair for large paraoesophageal hernias and selected reflux cases.
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Weight loss
The single biggest medical lever — 5-10% loss meaningfully reduces reflux from a sliding hiatus hernia.
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PPI + lifestyle
Proton pump inhibitor with meal timing, head-of-bed elevation and reduced alcohol — the first-line combination.
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H2 blockers
Famotidine as top-up or alternative when PPIs are not tolerated.
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Prokinetic (specific cases)
A prokinetic agent in selected patients with delayed gastric emptying alongside reflux.
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Laparoscopic hiatal repair + fundoplication
Keyhole repair of the hiatus with a fundoplication wrap — the standard operation.
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Nissen or Toupet fundoplication
Full 360° (Nissen) or partial 270° (Toupet) wrap — choice depends on motility and surgeon preference.
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LINX magnetic sphincter
A magnetic ring around the lower oesophageal sphincter — a specialist alternative for selected reflux patients.
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Large paraoesophageal repair
Surgery is often recommended for large paraoesophageal hernias to prevent strangulation and volvulus.
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 surgeon knows your history and can tell you which parts apply to you. If in doubt, see them.
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NICE. Dyspepsia and gastro-oesophageal reflux disease in adults (CG184).
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Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for the management of hiatal hernia.
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British Society of Gastroenterology. Guidelines on reflux and hiatus hernia.
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Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS).
Red flags
When a hiatus hernia becomes urgent.
Most hiatus hernias are quiet. These are the situations that need urgent review — and the one that needs 999.
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Gastric volvulus
Chest pain with retching but inability to vomit — a surgical emergency, call 999.
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Strangulation
Severe pain, systemic upset and bleeding — immediate hospital assessment.
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Iron-deficiency anaemia
Especially with a known hernia — investigate for Cameron lesions and other bleeding sources.
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Weight loss with dysphagia
Always rule out oesophageal or gastric cancer with urgent endoscopy.
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Barrett’s oesophagus development
Chronic reflux from a sliding hernia can drive Barrett’s — surveillance endoscopy is standard.
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Post-op complications
Persistent dysphagia or gas-bloat after fundoplication — see your surgeon for review.
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Recurrent hernia post-repair
Symptoms returning after surgery warrant repeat imaging and specialist opinion.
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Pregnancy with severe symptoms
Reflux is common in pregnancy — severe or resistant symptoms need specialist review.
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Post-bariatric patient with reflux
Reflux after gastric surgery has specific causes — get bariatric surgical input.
Living with it
A long-term issue, but a very manageable one.
Four things that make the biggest difference day to day — meals, sleep, long-term medication and knowing which type of hernia you have.
A quiet reminder
Consistency beats intensity, every time.
Small, steady changes — kept up for months — do more than a heroic week that does not last.
- 01 Meals
Timing matters more than diet
Finishing meals 3+ hours before bed helps more than eliminating any single food.
- 02 Sleep
Raise the head of the bed
Under the bed legs, not with pillows — one of the highest-yield changes.
- 03 Long-term
PPIs are safe but not neutral
Effective long-term, but review annually and try to step down where possible.
- 04 Follow-up
Know your hernia type
A large paraoesophageal hernia has different follow-up needs — keep in touch with your surgeon.
Frequently asked
Everything we get asked about hiatus hernia.
Quick answers on sliding vs paraoesophageal hernias, fundoplication, LINX and when to worry.
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What is the difference between a sliding and paraoesophageal hiatus hernia?
A sliding (type I) hernia is when the junction between the oesophagus and stomach slides up into the chest — the most common type, and the one that usually causes reflux. A paraoesophageal (types II-IV) hernia is when part of the stomach herniates alongside a normally positioned junction — less common but with a higher risk of strangulation and gastric volvulus.
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How is a hiatus hernia diagnosed?
Most are found on upper GI endoscopy or on CT imaging done for another reason. Manometry and 24-hour pH monitoring are added when surgery for reflux is being considered.
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Do all hiatus hernias need surgery?
No. Sliding hernias are managed as reflux — lifestyle, PPIs and surgery only for selected patients. Large paraoesophageal hernias are often repaired to prevent strangulation and volvulus.
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What is a fundoplication?
A fundoplication wraps the top of the stomach around the lower oesophagus to reinforce the valve mechanism. A Nissen is a 360° wrap; a Toupet is a partial 270° wrap. Both are typically done laparoscopically alongside repair of the hiatus.
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What is LINX?
LINX is a small ring of magnetic beads placed around the lower oesophageal sphincter. It is a specialist alternative to fundoplication for selected patients with confirmed reflux.
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When should I call 999?
Sudden severe chest or abdominal pain, especially with retching and inability to vomit, can be gastric volvulus — a surgical emergency. Call 999.
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