A hiatal hernia occurs when parts of the stomach protrude into the chest cavity through an opening in the diaphragm. The diaphragm separates the abdominal cavity from the chest cavity. For this reason, a hiatal hernia is also known as a diaphragmatic hernia. A hiatal hernia is not an inguinal hernia in the strict sense, such as an inguinal hernia. The opening in the diaphragm, known as the esophageal hiatus, is a necessary anatomical structure and not a weak spot in the tissue, as is the case with other types of hernias.
The esophagus runs from the throat through the esophageal hiatus to the stomach in the abdominal cavity. Under certain circumstances, parts of the stomach can pass through this opening into the chest cavity. A hiatal hernia does not protrude from the inside of the body to the outside, as with an inguinal hernia or an umbilical hernia. It is therefore classified as an internal hernia.
Healthy junction between the stomach and the esophagus. The diaphragm surrounds this junction © bilderzwerg | AdobeStock
In principle, three different types of diaphragmatic hernias can be distinguished:
- cardiofundal malformation,
- the axial hernia (sliding hernia), and
- the paraesophageal hiatal hernia.
Cardioportal malformation is the mildest form of hiatal hernia. In this condition, the ligaments that attach the stomach to the diaphragm have previously loosened. As a result, the esophagus enters the stomach at a more obtuse angle than the so-called esophagogastric angle or His angle. Symptoms resulting from cardiofundal malformation occur only in the rarest of cases.
In a paraesophageal hiatal hernia, parts of the stomach push through the esophageal hiatus alongside the esophagus, entering the chest cavity from below. This can lead to a narrowing of the stomach and, in extreme cases, to what is known as an “upside-down stomach.” In an “upside-down stomach,” the entire stomach lies above the diaphragm.
An axial hernia is also known as a sliding hernia. In this condition—as with a paraesophageal hernia—the upper part of the stomach slides upward through the esophageal hiatus into the chest cavity. This also disrupts the function of the esophageal sphincter. In this case, stomach contents can flow back into the esophagus. This is also known as reflux disease. Axial hernias account for 90 percent of all hiatal hernias, making them the most common type.
The hiatal hernia is the most common type of internal hernia. Men are affected more frequently than women. For example, among people aged 50 and older, about twice as many men as women develop a hiatal hernia.
Overall, the likelihood of developing a hiatal hernia increases with age.
In addition, a hiatal hernia can occur as a late complication following surgery in the upper abdomen. In some cases of hiatal hernia, parts of the stomach protrude far into the chest cavity, which distorts the entrance to the stomach and promotes the reflux of stomach acid. In rare cases, bleeding or entrapment of abdominal organs may also occur.
Symptoms often worsen after large meals because more pressure is exerted on the diaphragm, causing the tissue to shift more easily. Larger diaphragmatic hernias, in particular, can become dangerous if parts of the stomach become trapped and blood flow is compromised—in such cases, prompt treatment is necessary.
A diaphragmatic hernia can be either congenital or acquired. An acquired diaphragmatic hernia results from an enlargement or dilation of the esophageal hiatus. The cause is usually generalized weakness of the diaphragm’s connective tissue combined with prolonged increased pressure in the abdominal cavity.
For this reason, people who are severely overweight are at an increased risk of developing a hiatal hernia.
Other risk factors for developing a diaphragmatic hernia include
- pregnancy,
- advanced age, and
- being male.
In addition, abdominal surgery can also increase the risk of developing a hiatal hernia.
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In sliding hernias, abdominal organs temporarily move upward through the hiatus, often without being noticed. Smaller diaphragmatic hernias, in particular, often remain asymptomatic for a long time, so symptoms do not appear until reflux or feelings of pressure become more severe. A gastroscopy helps detect such changes early and accurately assess the severity of the hernia.
If, in the case of a severe hiatal hernia, parts of the stomach permanently enter the chest cavity, the diaphragm can be pushed back into the abdominal cavity. This exacerbates reflux problems and other symptoms. In such cases, targeted treatment is important to alleviate symptoms and prevent complications.
Heartburn is a symptom of a hiatal hernia © onephoto | AdobeStock
Signs of a diaphragmatic hernia
A hiatal hernia may or may not cause symptoms. The nature of the symptoms depends on the specific type of hiatal hernia.
Possible symptoms that may occur with a hiatal hernia include, among others
- heartburn,
- anemia,
- feeling of fullness,
- belching,
- difficulty swallowing, and
- apnea.
If parts of the stomach become trapped in the hiatus of the diaphragm, stomach pain or pain in the upper abdomen or chest may also occur.
Additional symptoms may occur if a diaphragmatic hernia is suspected and the upper part of the stomach regularly slips into the chest cavity. In the case of an axial hiatal hernia, reflux, chronic cough, or recurrent inflammation of the esophagus are typical—often worsened after meals or when lying down. If a large hiatal hernia is overlooked, symptoms usually worsen, so those affected should seek medical attention early on.
In rarer cases, diaphragmatic hernias can take a more serious course, such as when parts of the stomach become trapped and surgery is required. Congenital diaphragmatic hernias also occur in newborns and are usually medical emergencies, as abdominal organs can displace the lungs. Regardless of the type, a hospital should be consulted as soon as severe symptoms occur or symptoms rapidly worsen.
Diagnosis and Treatment of Diaphragmatic Hernias
To diagnose a diaphragmatic hernia, the doctor first interviews the patient about their symptoms as part of a medical history discussion. If the patient reports symptoms such as heartburn, this may indicate the presence of gastroesophageal reflux disease (GERD) and a hiatal hernia.
However, a definitive diagnosis of a diaphragmatic hernia is only possible through imaging studies. These include, for example,
During an esophagoscopy, doctors can look for signs of a hiatal hernia © romaset | AdobeStock
Milder symptoms, such as heartburn, can usually be treated with medication at first.
However, a hiatal hernia can also impair vital functions, such as breathing. There is also a risk of organ injury. In these cases, hiatal hernia surgery must be performed as part of hernia surgery.
Various surgical options are available for this procedure:
- fundoplication (either according to Nissen and Rosetti or according to Toupet),
- gastropexy or fundopexy, and
- hiatoplasty.
In fundoplication, a cuff is formed from portions of the stomach and placed around the lower part of the esophagus. In gastropexy (fundopexy), the stomach is repositioned to its normal location and sutured to the anterior abdominal wall. In hiatoplasty, the opening in the diaphragm (esophageal hiatus) is closed with sutures.
When is a hiatal hernia noticed?
A hiatal hernia is usually asymptomatic, so symptoms may not appear for a long time. Only when parts of the stomach protrude through the diaphragm or stomach acid rises into the esophagus do symptoms such as heartburn or pressure behind the breastbone occur.
Can a small hiatal hernia be dangerous?
A small hiatal hernia rarely causes immediate problems. It becomes problematic if the stomach continues to protrude through the diaphragm or if an ulcer develops—in such cases, a medical evaluation should be conducted.
How does the hernia affect the chest cavity?
If the stomach moves through the diaphragm into the chest cavity, in extreme cases it can even affect the lung on the affected side. This leads to breathing difficulties or a feeling of tightness.
What role does the connection between the esophagus and the stomach play?
Due to the altered position, the junction between the esophagus and the stomach can no longer seal properly. As a result, stomach acid flows back more easily, causing pain and irritation of the mucous membranes.
When is surgery necessary?
Surgical treatment is recommended if symptoms persist despite therapy, if complications arise, or if the upper part of the stomach slips into the chest cavity. In such cases, the hernia should be stabilized and the stomach repositioned to its correct location.
