Hiatal Hernia

In a hiatal hernia (also called hiatus or diaphragmatic hernia), a portion of the stomach penetrates (herniates) through a weakness or tear in the hiatus of the diaphragm, the small opening that allows the esophagus to pass from the neck and chest to its connection with the stomach. Often there are no symptoms, and the condition may not cause any problems. The patient may not be aware they have a hiatal hernia.

Sliding Hiatal Hernia

The term sliding is employed when hiatal hernia involves the lower esophageal sphincter where the esophagus attaches to the stomach. It can also involve a small portion of the stomach. The patient may experience heartburn and gastroesophageal reflux. Because reflux may damage the lining of the esophagus, treatment is essential. Symptoms can usually be managed with medications and behavior modification such as elevating the upper body on a pillow during sleep. Surgery may sometimes be required to correct a sliding esophageal hernia.

Paraesophageal Hernia and Intrathoracic Stomach

In more severe cases of hiatal hernia, the fundus, or upper portion of the stomach, may slide upward into the chest cavity through the hiatus. The condition occurs as an intensifying of a sliding hiatal hernia. In rare cases, the entire stomach and even some of intestines may migrate through the hiatus and rest on top of the diaphragm next to the esophagus, a condition known as giant esophageal hernia.

Giant Hiatal Hernias: Podcast by Lyall A. Gorenstein, MD »  

Risk Factors

Hiatal hernia is initiated by pressure in the abdomen occurring through:

  • Heavy lifting
  • Hard coughing or sneezing
  • Violent vomiting
  • Pregnancy and delivery
  • Obesity may also cause hiatal hernia because of pressure on the abdomen
    caused by extra weight.
  • Heredity
  • Smoking
  • Stress
  • Short esophagus (paraseophageal hernia)

Signs and Symptoms

Most small hiatal hernias do not cause symptoms. The most common symptom of hiatal hernia is gastroesophageal reflux (GERD).

Giant hiatal hernias may cause symptoms including heartburn/regurgitation, anemia, aspiration, chest pain associated with eating, vomiting after meals, difficulty swallowing, fatigue, and shortness of breath.

Symptoms of parasophageal hernia may include problems swallowing, fainting, and vomiting.


Hiatal hernia is diagnosed with an upper GI series or endoscopy.

In an upper GI series, or a barium swallow, also called barium contrast X-ray, the patient swallows a solution of barium, a compound that will appear inside the body during X-ray so the physician may observe how fluid moves through the esophagus as well as the appearance of the stomach.

In esophagoscopy/endoscopy of the esophagus, a thin, flexible tube with a camera is inserted through the mouth into the esophagus, allowing the physician to view the interior of the esophagus and obtain small tissue samples for biopsy, if necessary.


Hiatal hernias require repair for two main reasons:

  1. The patient's reflux symptoms are not successfully controlled with GERD medication therapy.
  2. The patient has a giant esophageal hernia (also known as intrathoracic stomach.)

If surgical treatment is required, our surgeons nearly always use minimally invasive anti-reflux techniques, including laparoscopy and endoscopy, with the type of procedure used depending upon the amount of stomach that has migrated through the diaphragm into the chest. GERD medications are not necessary after surgery.

Repairing the Hiatus

An early-stage hiatal hernia may be repaired by decreasing the size of the enlarged hiatus (the opening in the diaphragm through which the esophagus travels on its way to the stomach). This is accomplished by means of sutures and a prosthetic mesh to reinforce the diaphragm tissue.

Nissen Fundoplication

The fundus (top of stomach) is wrapped around the esophogastric junction (the connection between the stomach and the lower esophagus).To repair and prevent a sliding hiatal hernia, Nissen fundoplication involves wrapping of the fundus (upper part) of the stomach around the bottom portion of the esophagus to create a bulge of tissue that holds the stomach in place below the diaphragmatic hiatus. Nissen fundoplication also reinforces the lower esophageal sphincter and alleviates reflux when it is present.

Collis-Nissen Gastroplasty

Paraesophageal hernia and intrathoracic stomach may be complicated when a short esophagus pulls upward on the stomach. In Collis-Nissen gastroplasty, the surgeon uses the upper portion of the stomach to extend the esophagus and ease this tension. Our team routinely uses minimally invasive laparoscopy to perform this procedure, which was traditionally performed through a major chest incision.