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Ask the Doctors: Hiatal Hernias

A hernia occurs when part of an internal organ or tissue pushes through a weak spot in your muscle. Most hernias happen when the intestines bulge through a tear in the abdominal wall. Hernias are very common and are usually treated with surgery. The Food and Drug Administration estimates that about one million hernia repairs are performed each year in the United States.

While most hernias occur when the intestines push through the abdominal wall and cause a visible lump and pain in the affected area, some hernias are different.

A hiatal hernia is a different kind of hernia that affects the diaphragm and might not show any symptoms for some people. Washington University cardiothoracic surgeon Shuddhadeb Ray, MD, MPHS, sees a large number of hiatal hernia patients at Christian Hospital in North St. Louis. An expert in minimally invasive surgery for hernia repair, Ray answers some frequently asked questions about hiatal hernias.

Hiatal Hernia Frequently Asked Questions

What is a hiatal hernia?

A hiatal hernia is when part of the stomach pushes through an opening in the diaphragm and up into the chest cavity.

The diaphragm separates the chest from the abdomen. The opening in the diaphragm, called the esophageal sphincter, is where the esophagus and stomach join. Normally, this sphincter is closed tight so that stomach acid does not flow up into the esophagus and cause acid reflux.

Illustration of the stomach and esophagus, showing normal anatomy compared to a hiatal hernia
A hiatal hernia happens when the stomach pushes up into the chest.

Unlike inguinal or incisional hernias that typically happen in the abdomen, hiatal hernias are located in the chest. Abdominal wall hernias may look like a bulge in the stomach or groin, but a hiatal hernia happens inside the chest and is not typically visible from the outside.

Hiatal hernias are most common in women and people over age 50.

What causes a hiatal hernia?

Hiatal hernias can happen if the muscles that separate the chest from the abdomen are weak or if the esophageal sphincter is large. Increased abdominal pressure can cause a hiatal hernia. Causes for increased abdominal pressure may include:

  • Chronic coughing
  • Vomiting
  • Straining during a bowel movement
  • Straining during physical activity or exercise
  • Heavy lifting
  • Obesity
  • Pregnancy

What are the symptoms of a hiatal hernia?

“Many people don’t know that they have a hiatal hernia because they are asymptomatic,” says Ray. “Other people have symptoms such as reflux, abdominal or chest pain, regurgitation or difficulty breathing or swallowing.”

Diagnosing a hiatal hernia can be difficult. Many people do not have any symptoms, while some people experience the symptoms of gastroesophageal reflux disease (GERD).

The most common symptoms of a hiatal hernia are:

  • Difficulty swallowing
  • Chest or abdominal pain
  • Reflux
  • Regurgitation

There is about a 15% chance of an asymptomatic hiatal hernia becoming symptomatic each year.

How is a hiatal hernia treated?

Medications and lifestyle changes to manage the symptoms of a small hiatal hernia might work for some people.

Hiatal hernias can cause more severe symptoms in some cases. If the hernia becomes strangulated it could cut off blood supply to the stomach. Though uncommon, there is about a 1-2% risk of a hiatal hernia developing acute issues that would require emergency surgery.

Ray encourages patients experiencing symptoms to seek out care before their situation becomes an emergency. “If there is evidence of a hiatal hernia and they have any of those symptoms, it’s worth being evaluated by a surgeon,” he says.

Ray performs minimally invasive hiatal hernia repair surgery at Christian Hospital in North St. Louis.

This laparoscopic approach involves just five small incisions and ports, all less than one centimeter in size. Using small instruments and a camera, Washington University hernia surgeons reduce the size of the hernia and the hole in the diaphragm. Surgeons can also wrap the top of the stomach around the bottom end of the esophagus (called fundoplication) to prevent the stomach from going back up into the chest and to prevent reflux.

“Their surgery is generally only about two to three hours long. They stay for about two days in the hospital. They’ve done very well overall in terms of their symptoms, which is a relief from regurgitation, reflux and pain, and a majority of them can get back to their daily activities quite quickly,” Ray says. “It is generally a low-risk procedure that allows people to have their symptoms addressed and usually reduces their reliance on proton-pump inhibitors, or medication for reflux. And most importantly, it can prevent it from becoming an emergent situation.”

Washington University Hiatal Hernia Surgeons

Washington University hernia surgeons see patients at the Center for Advanced Medicine, Barnes-Jewish West County Hospital and Christian Hospital.

Minimally invasive and cardiothoracic surgeons provide expert laparoscopic surgical care for patients with hiatal hernias and GERD.

For more information about hernia surgery, or hernia patient appointments at the Center for Advanced Medicine or Barnes-Jewish West County Hospital, please call 314-454-8877.

For more information about Christian Hospital, or to schedule an appointment with Dr. Ray, visit the Christian Hospital website or call 314-747-9355.

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