Hiatus hernia
The diaphragm is the muscular sheet dividing the chest from the abdomen, and the oesophagus passes through it at a narrow opening.
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Medicines commonly prescribed for Hiatus hernia
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 20 mgActive substance: pantoprazoleManufacturer: Aurovitas Spain, S.A.U.Prescription requiredDosage form: TABLET, 40 mg pantoprazoleActive substance: pantoprazoleManufacturer: Takeda GmbhPrescription requiredDosage form: TABLET, 40 mg/tabletActive substance: pantoprazoleManufacturer: Teva Pharma S.L.U.Prescription required
The diaphragm is the muscular sheet dividing the chest from the abdomen, and the oesophagus passes through it at a narrow opening. Muscle bundles wrap around that opening like a sling and, together with the valve at the bottom of the oesophagus, keep stomach contents from travelling upwards. When the sling slackens, the upper part of the stomach rides up into the chest — that is a hiatus hernia. It is found extremely often, particularly in later life, and in most people it says nothing at all. The trouble is rarely the hernia itself; it is the valve that has stopped closing.
Sliding and para-oesophageal: a difference that matters
Two rather different conditions share one name, and they are worth keeping apart.
The sliding type accounts for roughly nine cases in ten. The junction between oesophagus and stomach, along with a small piece of the stomach itself, slips upwards along the line of the oesophagus and drops back when the person stands. The angle at which the oesophagus meets the stomach straightens out and the valve seals less well. Hence the whole familiar catalogue of complaints: burning and reflux.
The para-oesophageal type behaves differently. The junction stays put while the dome of the stomach bulges up beside the oesophagus through the same opening. There may be no burning whatsoever, but the displaced portion can become trapped or twist on itself. These hernias are less common, and they are the ones that produce emergencies. There are also mixed hernias and large ones, in which a substantial share of the stomach sits above the diaphragm.
What it feels like
A small sliding hernia is usually stumbled upon — at a gastroscopy done for something else, or on an X-ray. When there are symptoms, they form a recognisable picture:
- burning behind the breastbone, typically half an hour to an hour after eating, on bending forward and on lying down;
- acid or bitter fluid rising into the throat, sometimes with scraps of food, especially at night;
- frequent belching, feeling full on small portions, bloating high in the abdomen;
- chest pain that is easily mistaken for something cardiac;
- a sour taste on waking, bad breath, worn enamel on the back teeth;
- a dry night-time cough, morning hoarseness, a lump in the throat, asthma-like episodes of tightness;
- a sense that food is travelling slowly and sticking behind the breastbone.
How much it hurts and how big the hernia is have little to do with each other. Someone with a large hernia may notice nothing, while a small one ruins sleep for years.
When to call an ambulance
This is the rare but genuinely dangerous side of the subject, and it is almost never mentioned in ordinary talk about hiatus hernia. If the displaced part of the stomach becomes trapped in the opening or twists, its blood supply is cut off and the clock runs in hours. Call an ambulance — in Spain, Italy, Portugal, Poland and Ukraine that is the single European number 112 — if any of these appear:
- sudden severe pain high in the abdomen or behind the breastbone that builds and does not let go;
- persistent retching with nothing coming up, or vomiting that brings no relief;
- being unable to swallow even saliva;
- sudden swelling and tightness across the upper abdomen;
- vomiting blood, or dark material resembling coffee grounds;
- black, tarry stools;
- severe chest pain with breathlessness, sweating, or pain spreading to the arm, neck or jaw — here the heart is ruled out first.
Do not drive yourself in that state. Take a list of your medicines with you.
Signs that should not wait
Ordinary heartburn can be managed at home for a while, but some complaints point past a hernia to more serious things: a narrowed oesophagus, deep ulcers, a tumour. Arrange to see a doctor within days if:
- swallowing is getting steadily harder, solids first and later liquids too;
- swallowing hurts;
- weight is falling without you trying;
- vomiting has become constant;
- a blood test has shown anaemia or iron deficiency with no obvious cause;
- heartburn has appeared for the first time later in life, or has abruptly changed character;
- symptoms persist beyond three weeks despite pharmacy remedies.
Barrett's oesophagus deserves separate mention. Years of acid washing upwards remodel the lining of the lower oesophagus, and it is on that altered lining that oesophageal cancer occasionally develops. The risk to any one person is small, and that is exactly why long-standing heartburn is not left unexamined: the point is to decide whether gastroscopy and follow-up are warranted.
What helps most
Nothing done at home will put the stomach back where it belongs, but stopping the reflux is entirely realistic, and for a good many people that is where treatment ends.
- Losing weight if there is weight to lose. Of everything on this list it does the most work: fat around the middle presses from below and pushes the stomach up. Even a few kilograms shift matters noticeably.
- Raising the head of the bed. Put blocks under the legs at the head end, or a wedge under the mattress, so the top rises by a good hand's width. Piling up pillows does not work: it folds the body in half and simply raises abdominal pressure.
- Eating three to four hours before bed. Night-time reflux does the most damage, because the acid sits in the oesophagus for a long stretch.
- Smaller portions, more often. An overfilled stomach opens the valve nearly every time.
- Loose clothing. A tight belt or shapewear works like a press.
- Stopping smoking. Nicotine relaxes the valve at the bottom of the oesophagus, and in smokers heartburn is more stubborn.
- Alcohol, particularly in the evening. It relaxes the same valve and irritates the lining.
- Your own triggers. There is no universal list of forbidden foods. Coffee, chocolate, mint, spicy and fatty dishes, acidic juices and fizzy drinks come up most often, but everyone's set differs — a week of brief notes is more use than crossing out everything at once.
- Not lying down or bending straight after a meal, and lifting with the legs rather than the belly.
The medicine cabinet is worth reviewing too. Painkillers from the non-steroidal anti-inflammatory group irritate the lining and make symptoms worse, and some drugs for blood pressure and angina relax the valve. Do not stop a prescribed treatment on your own — that is a conversation with a doctor, who can find a substitute.
Medicines and where they stop
Two groups are sold over the counter. Antacids neutralise acid that has already been produced: they act quickly but not for long. Alginates form a dense raft on top of the stomach contents that physically gets in the way of reflux, and they suit the period after meals and bedtime best. Both are taken a little while after eating, when symptoms are most likely.
These are remedies for occasional episodes, not for permanent use. If they are needed every day for weeks, the plan is wrong and a doctor is needed: they may prescribe drugs that reduce acid production — proton pump inhibitors or H2 receptor blockers — in courses that are then reviewed. Taking them for years without oversight is not harmless, and it masks warning signs into the bargain.
Not everything is suitable in pregnancy, so any medicine then is worth discussing with a doctor or pharmacist. The reassuring part is that heartburn in pregnancy usually settles soon after the birth.
How it is worked out
Most often the diagnosis is made at gastroscopy: the doctor sees the displaced junction and assesses the lining at the same time — inflammation, erosions, narrowing, altered cells. A contrast X-ray shows the shape and size of the hernia and is particularly useful in the para-oesophageal form. Manometry measures pressures inside the oesophagus and how its muscle works, and a twenty-four-hour acid recording answers whether the symptoms really are down to reflux. The full set is seldom required: a conversation, an examination and one or two tests usually settle it.
When surgery comes up
An operation is not the first step but the answer for a minority. It comes back onto the table when drugs and habits are not enough, when someone is unwilling to take medicines for decades, when complications appear such as a narrowed oesophagus or bleeding ulcers, and in large para-oesophageal hernias where there is a real risk of the stomach becoming trapped.
It is done laparoscopically: a few small cuts in the abdomen, under general anaesthetic. The surgeon returns the stomach to the abdomen, closes the widened opening in the diaphragm, and wraps the top of the stomach around the oesophagus as a cuff to restore the valve.
Worth knowing in advance: for the first weeks food is soft and a normal diet returns gradually. For a time there may be difficulty swallowing, bloating and an inability to belch, which generally settle. In some people the symptoms come back over the years and a second operation is discussed. That is why the decision is made together with the surgeon, weighing how much the condition really interferes with living.
Online consultation
In an online consultation the doctor will go through your symptoms in detail: when the burning appears, whether it follows meals and posture, whether there is reflux and coughing at night, what you have already tried and with what result. Warning signs get checked separately — difficulty swallowing, weight loss, traces of blood, anaemia — and you will be asked what medicines you take, since several of them worsen reflux. By the end it will be clear whether adjusting habits and choosing a drug is enough, or whether it is time for a gastroscopy.
This material is for information only and does not replace medical advice.
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