Hiatal Hernia

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1- Introduction

2- Anatomical Overview

3- Causes

4- Treatment


A hiatal hernia occurs when part of the stomach protrudes upward through the diaphragm into the chest cavity. The diaphragm is the muscle that separates the abdomen from the chest. Hiatal hernias are relatively common and can occur in people of all ages, although they are more common in individuals over the age of 50.

© image from Moore Clinically Oriented Anatomy

Anatomical Overview

A hiatal (hiatus) hernia is a protrusion of part of the stomach into the mediastinum through the esophageal hiatus of the diaphragm. The hernias occur most often in people after middle age, possibly because of weakening of the muscular part of the diaphragm and widening of the esophageal hiatus. Although clinically there are several types of hiatal hernia, the two main types are paraesophageal hiatal hernia and sliding hiatal hernia (Skandalakis et al., 1996). In the less common para-esophageal hiatal hernia, the cardia remains in its normal position. However, a pouch of peritoneum, often containing part of the fundus of the stomach, extends through the esophageal hiatus anterior to the esophagus. In these cases, usually no regurgitation of gastric contents occurs because the cardial orifice is in its normal position. In the common sliding hiatal hernia, the abdominal part of the esophagus, the cardia, and parts of the fundus of the stomach slide superiorly through the esophageal hiatus into the thorax, especially when the person lies down or bends over. Some regurgitation of stomach contents into the esophagus is possible because the clamping action of the right crus of the diaphragm on the inferior end of the esophagus (the lower “esophageal sphincter”) is weak.

© image from Moore Clinically Oriented Anatomy


  • Weakness in the Diaphragm: The diaphragm is a large muscle that separates the chest cavity from the abdomen and plays a crucial role in breathing. Weakness in the diaphragm can occur due to various reasons, including aging, trauma, congenital factors, or chronic pressure on the area.

  • Increased Intra-Abdominal Pressure: Conditions or activities that increase pressure within the abdomen can contribute to the development of hiatal hernias. These may include obesity, pregnancy, frequent heavy lifting, chronic coughing, or straining during bowel movements.

  • Age: Hiatal hernias are more common in older adults, possibly due to age-related changes in muscle tone and connective tissue integrity. As people age, the tissues supporting the hiatus may weaken, making them more susceptible to herniation.

  • Genetic Predisposition: Some individuals may have an inherited tendency to develop hiatal hernias. Family history and genetic factors may play a role in determining an individual’s susceptibility to developing a hernia.

  • Smoking: Smoking has been associated with an increased risk of developing hiatal hernias. It is believed that smoking may weaken the muscles and connective tissues in the diaphragm and increase intra-abdominal pressure, making herniation more likely.

  • Heavy Lifting: Regularly lifting heavy objects or engaging in activities that require straining can increase pressure within the abdomen and contribute to the development of hiatal hernias.

  • Trauma or Injury: Trauma or injury to the chest or abdomen, such as a severe blow to the area, can potentially weaken the diaphragm or disrupt the supportive structures around the hiatus, increasing the risk of herniation.


  • Lifestyle Modifications:

    • Dietary Changes: Avoiding large meals, spicy foods, acidic foods, caffeine, and alcohol may help reduce symptoms of acid reflux and heartburn associated with hiatal hernias.
    • Weight Loss: Losing excess weight, if overweight or obese, can help reduce intra-abdominal pressure and alleviate symptoms of hiatal hernia.
    • Elevating the Head of the Bed: Raising the head of the bed by 6 to 8 inches can help prevent acid reflux during sleep by keeping stomach acid from flowing back into the esophagus.
    • Avoiding Tight Clothing: Tight clothing, especially around the waist and abdomen, can increase intra-abdominal pressure and worsen symptoms of hiatal hernia.
  • Medications:

    • Antacids: Over-the-counter antacids can help neutralize stomach acid and provide temporary relief from symptoms such as heartburn and acid reflux.
    • Proton Pump Inhibitors (PPIs): PPIs reduce the production of stomach acid and are often prescribed for individuals with persistent or severe symptoms of acid reflux associated with hiatal hernias.
  • Surgical Intervention:

    • Hernia Repair Surgery: In some cases, surgical intervention may be necessary to repair the hiatal hernia, particularly if symptoms are severe, do not respond to conservative measures, or if complications such as strangulation or obstruction occur. Surgical procedures for hiatal hernia repair may involve laparoscopic or open surgery techniques to reposition the stomach and repair the opening in the diaphragm.
    • Fundoplication: In addition to repairing the hernia, a fundoplication procedure may be performed during surgery to strengthen the lower esophageal sphincter and reduce acid reflux.
  • Monitoring and Follow-Up:

    • Regular monitoring by a healthcare provider is important for individuals with hiatal hernias, especially if symptoms persist or worsen over time. Follow-up appointments may involve symptom assessment, evaluation of treatment effectiveness, and adjustments to the treatment plan as needed.
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