Conditions / Hiatal Hernia

Hiatal Hernia-Associated Reflux

Affects an estimated 50%+ of GERD endoscopy patients

Overview

A hiatal hernia occurs when part of the stomach pushes up through the diaphragmatic hiatus into the chest. This disrupts the LES mechanism — the diaphragm normally reinforces the LES, and when the stomach herniates upward, this reinforcement is lost.

How it's diagnosed

Upper endoscopy identifies size and type. Barium swallow x-ray shows the defect. Esophageal manometry measures LES pressure. CT chest can evaluate large hernias.

Triggers

  • Increased intra-abdominal pressure: coughing, vomiting, heavy lifting
  • Obesity significantly worsens it
  • Pregnancy
  • All GERD dietary triggers are amplified with hiatal hernia

Symptoms

  • More severe GERD symptoms than typical
  • Difficulty swallowing
  • Chest pain especially with paraesophageal type
  • Shortness of breath (large hernias)
  • Gurgling sounds in chest

Complications if untreated

Immediate relief

  • Same as GERD: elevate, upright posture, antacids

Long-term management

  • Surgical repair (laparoscopic fundoplication) for symptomatic large hernias
  • Weight loss reduces herniation pressure
  • Avoid all high-pressure activities post-meals
  • PPIs often insufficient alone — surgery may be needed

Diet

Extra emphasis on very small meals — large meals dramatically worsen symptoms by increasing gastric pressure. 5–6 small meals strongly preferred.

When to see a doctor

Paraesophageal hernias require surgical evaluation. Sudden severe chest pain with inability to belch = emergency room. Large hernias (>5cm) often require surgical repair.

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