Hiatal hernia is a condition that may be associated with heartburn, acid reflux, and difficulty swallowing, although it can also occur without noticeable symptoms. The condition develops when the upper part of the stomach protrudes through an opening in the diaphragm into the chest cavity. So, what are the causes of hiatal hernia? Is its development associated with aging, obesity, or physical exertion? In this article, we explore the main causes and risk factors, diagnostic methods, and when treatment or surgical intervention may be necessary.
Medical Review: This article has been medically reviewed by Dr. Ahmed Abu Kheima, Consultant in General Surgery, Gastrointestinal Surgery, and Surgical Oncology.
What Is a Hiatal Hernia and How Does It Develop?
The diaphragm is a muscle that separates the chest cavity from the abdominal cavity. The esophagus passes through an opening in the diaphragm before connecting to the stomach. A hiatal hernia occurs when the upper part of the stomach protrudes through this opening into the chest due to weakness in the surrounding tissues or widening of the opening.
A small hernia may not cause any noticeable problems, while a larger hernia may be associated with stomach acid reflux into the esophagus or difficulty swallowing. The condition varies from person to person depending on the size and type of the hernia and its effect on the valve between the esophagus and stomach. Therefore, discovering a hiatal hernia does not necessarily mean surgery is required. The decision depends on an assessment of the condition, symptoms, and potential complications.
Causes of Hiatal Hernia
There is no single confirmed cause of all cases of hiatal hernia. However, weakness in the tissues surrounding the esophageal opening and increased abdominal pressure are important factors associated with its development. A hernia may develop gradually with age or be associated with a previous injury or a congenital difference in the size of the opening. The main contributing factors include:
Weakness in the tissues and muscles surrounding the opening in the diaphragm.
Repeated or sustained increases in abdominal pressure.
Age-related changes.
Injuries to the area or certain surgical procedures.
A wider-than-usual opening present from birth.
It is important to understand that having one of these factors does not necessarily mean a person will develop a hiatal hernia. The condition may also occur in people without any obvious risk factors.
What Are the Risk Factors for Hiatal Hernia?
Several factors may increase the likelihood of developing a hiatal hernia, particularly when they contribute to increased abdominal pressure or weaken the supporting tissues. The condition is more common among older adults and people with obesity. Other factors that may be associated with an increased risk include:
Obesity and excess weight: These place additional pressure on the abdominal area.
Pregnancy: Physical changes and increased abdominal pressure may contribute to the condition.
Chronic coughing or recurrent vomiting.
Chronic constipation: Particularly when accompanied by repeated straining during bowel movements.
Frequent heavy lifting: Especially when it involves significant physical strain.
Certain injuries or anatomical changes that affect the diaphragm.
These factors should not be considered direct causes in every case, as the development of a hiatal hernia depends on a combination of anatomical and functional factors.
What Symptoms of Hiatal Hernia Require Medical Attention?
A small hiatal hernia may not cause any symptoms and may be discovered incidentally during tests performed for other reasons. When symptoms do occur, they are often associated with stomach contents flowing back into the esophagus or the hernia affecting the movement of food. Possible symptoms include:
Heartburn, particularly after eating or when lying down.
Acid or food regurgitation into the mouth.
A feeling of fullness and bloating after meals.
Difficulty swallowing or a sensation that food is getting stuck in the esophagus.
Chest or upper abdominal pain or discomfort.
If symptoms persist or become more severe, you should consult a doctor to determine the cause. However, severe chest pain accompanied by shortness of breath or sweating, vomiting blood, or black stools requires urgent medical evaluation. These symptoms should not automatically be attributed to a hiatal hernia alone.
How Is a Hiatal Hernia Diagnosed?
Diagnosing a hiatal hernia involves assessing symptoms, medical history, and appropriate tests, as heartburn or chest pain alone cannot confirm its presence. Depending on the patient's condition, the doctor may recommend one or more of the following tests:
Upper gastrointestinal endoscopy: Helps examine the esophagus and stomach and identify inflammation or changes associated with acid reflux.
Barium swallow X-ray: Shows how the esophagus and stomach move during swallowing and may help determine the location and size of the hernia.
Esophageal manometry: Used when necessary to evaluate esophageal muscle contractions and function.
Esophageal pH monitoring: May be requested to assess acid reflux when symptoms persist or before certain treatment procedures.
The doctor determines which tests are necessary based on the symptoms and initial findings. Not every patient needs all these investigations.
What Are the Treatment Options for Hiatal Hernia?
Treatment depends on the size of the hernia, the severity of symptoms, and whether complications are present. Cases that cause no symptoms may not require specific treatment, while patients experiencing acid reflux may benefit from lifestyle modifications or appropriate medication. Measures that may help relieve symptoms include:
Eating smaller meals instead of large portions.
Avoiding lying down for two to three hours after eating.
Losing weight if excess weight is present.
Avoiding foods and drinks that trigger symptoms.
Elevating the head of the bed when experiencing nighttime reflux.
Taking medication prescribed by a doctor to reduce stomach acid when necessary.
These measures may relieve symptoms in some patients, but they do not permanently return the stomach to its normal position or anatomically close the hernia. Persistent or complicated cases therefore require medical evaluation.
When Do You Need Laparoscopic Hiatal Hernia Surgery?
A doctor may recommend laparoscopic hiatal hernia surgery if troublesome symptoms persist despite appropriate treatment, or if the hernia is large or associated with complications that require intervention. The procedure is performed through small incisions in the abdomen. The surgeon generally aims to return the stomach to its normal position and repair the widened opening. An additional procedure to reduce acid reflux may also be performed, depending on the patient's condition.
Before making a decision, the patient needs a thorough assessment of symptoms, hernia size, esophageal function, and overall health. Although laparoscopy may allow faster recovery than open surgery in suitable cases, it remains a surgical procedure with potential risks. Some symptoms may also persist or return after surgery. Therefore, surgery is not the first-line option for every patient.
Can Hiatal Hernia Be Prevented?
There is no guaranteed way to prevent a hiatal hernia because some causes are associated with aging or anatomical differences. However, certain habits may help reduce repeated abdominal pressure and improve control of reflux symptoms, particularly in people at increased risk.
Maintaining a healthy weight, treating chronic constipation and persistent coughing, avoiding excessive straining during bowel movements, and using proper techniques when lifting heavy objects may be beneficial. Avoiding smoking and following appropriate dietary habits when experiencing reflux symptoms are also recommended. These measures do not guarantee prevention, but they support digestive health and may help reduce certain factors associated with the condition.
Book Your Consultation with Dr. Ahmed Abu Kheima
If you experience frequent heartburn, acid reflux, or difficulty swallowing, do not rely on symptoms alone to determine the cause. An assessment by a specialist in gastrointestinal and laparoscopic surgery can help you understand your condition and identify the appropriate tests and treatment options.
You can book a consultation with Dr. Ahmed Abu Kheima at his clinic in Smouha, Alexandria, to evaluate your symptoms and discuss the available treatment options based on your condition.
For appointments and inquiries, call 01226222297 or 01006719949.
Frequently Asked Questions About the Causes of Hiatal Hernia
Does Obesity Cause a Hiatal Hernia?
Obesity is a risk factor associated with hiatal hernia because excess weight may increase abdominal pressure. However, it is not the only cause, and not everyone with obesity develops this condition.
Is a Hiatal Hernia Dangerous?
Most small hiatal hernias do not cause serious problems. However, some larger hernias may lead to severe acid reflux or complications that require medical intervention. The level of risk depends on the size of the hernia, the symptoms, and the medical examination findings.
Can a Hiatal Hernia Be Treated Without Surgery?
Yes. Many patients can manage their symptoms through lifestyle modifications and appropriate medication. However, these measures do not anatomically repair the hernia, and some cases may require surgery based on the doctor's assessment.
Can a Hiatal Hernia Cause Shortness of Breath?
A large hiatal hernia may be associated with shortness of breath in some patients, but this symptom has several possible causes. Medical evaluation is therefore necessary, particularly if the shortness of breath develops suddenly or is severe.
When Is Hiatal Hernia Surgery Necessary?
Surgery may be considered when severe symptoms persist despite treatment, or when a large hernia or complications require repair. The surgeon determines whether an operation is necessary after evaluating the test results and the patient's overall health.