What Is the Root Cause of a Hiatal Hernia?

A hiatal hernia is the bulging of the stomach through the muscle separating your diaphragm and abdomen. A hiatal hernia can be present at birth, or can develop over time and it develops after constant straining to the abdominal region.

Some kids have “innies” — some kids have “outies.” Does it mean anything? Even though it may just seem like a funny, wiggly thing, an outie is a medical condition known as a hernia.

A hernia is when an internal organ breaks through a weak spot in your connective tissue or muscle.  It can be painful, or have no symptoms at all. A hiatal hernia is the bulging of the stomach through the muscle separating your diaphragm and abdomen. The stomach contents can then get into your esophagus. A large hiatal hernia can be painful and cause other problems as well.

A hiatal hernia can be present at birth, or can develop over time.  It develops after constant straining to the abdominal region. The straining weakens your diaphragm muscles and allows the stomach to squeeze up through your diaphragm. Specific causes of a hiatal hernia can include:

• Injuries to the abdominal area, like after surgery or trauma 
• Age-related weakening of the diaphragm   
• Constant and intense pressure on muscles surrounding the abdomen/diaphragm area. 

The constant pressure or straining can come from activities you don’t even realize exert that much pressure. Examples include: 

• Coughing
• Vomiting
• Pregnancy
• Overexertion
• Bowel movement straining
• Heavy lifting
• Exercise

Hiatal hernias are seen more often in older people. Over time, the muscle in the diaphragm loses strength, elasticity, and flexibility  — allowing a hiatal hernia to form.   Other increased risks for hernia development include obesity, chronic obstructive pulmonary disease (COPD),  pregnancy, and chronic constipation —  all of which cause increased pressure within the abdominal cavity. 

Small hiatal hernias are usually painless and can be taken care of with medicine. Larger hernias may need surgery. Hiatal hernias are classed as one of four types:

• Type I — accounts for 95% of hernias, called sliding type. The gastroesophageal junction (where your stomach meets your esophagus) slides upward into the opening hiatus of the diaphragm.   
• Type II — also called paraesophageal — occurs when more of the stomach moves up and parallel to the esophagus.  
• Type III — a combination of sliding and paraesophageal herniation. Both the gastroesophageal junction and part of the stomach move into the esophagus.
• Type IV — most severe. The stomach and other organs like the intestines or spleen also move into the chest. 

Often, if you have a hiatal hernia, you will not even know. Only 9% of people with hiatal hernias have symptoms. This is true with a hernia that develops with pregnancy, for example. The hernia is not felt during the pregnancy, and may not be noticed until much later in life. Many times a hiatal hernia is an incidental finding when a doctor is performing tests for another condition. 

Smaller hiatal hernias may not have symptoms, but as they get larger you may experience:

• Heartburn 
• Difficulty swallowing 
• Acid reflux
• Vomiting  
• Abdominal bleeding 
• Chest pain 
• Anemia 
• Blood loss
• Digestion issues.

If symptoms get bad, or you have an extended period of “heartburn”, you need to see your doctor.  

As already mentioned, many times a hiatal hernia is an incidental finding. The doctor will be looking for the cause of your heartburn, chest pain, and abdominal pain. Testing procedures may include:

• X-ray of your upper digestive system 
• Upper endoscopy 
• Esophageal manometry 

Smaller hernias such as type I or sliding may not require treatment. You doctor may prescribe a restricted diet that avoids spicy foods. You may also be advised to not eat after a certain time, or not to lay down after eating.

If it is a bit more serious, antacids or proton pump inhibitors maybe given to you by your doctor. This is done to reduce stomach acid, which causes a lot of the symptoms of a hiatal hernia.

More severe hernias may need surgery. Under anesthesia, a laparoscopic procedure may be performed to pull the stomach back down, and put it back in place.  This type of procedure is called a Nissen fundoplication. Of patients who have this procedure done, 90% see improvement in their symptoms.