Hiatus Hernia: Symptoms, Causes & Treatment
The most common structural cause of acid reflux — sliding vs rolling types, why most need no surgery, and how the symptoms are controlled.
Part of the Complete Acid Reflux Guide.
Key fact: A hiatus hernia weakens the body’s main anti-reflux barrier — but treatment targets the reflux, not the hernia. Most people control symptoms fully with a daily PPI and practical changes, and never need surgery.
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Your diaphragm — the sheet of muscle separating chest from abdomen — has a small opening (the hiatus) through which the oesophagus passes on its way to the stomach. Normally the opening grips the oesophagus snugly, reinforcing the valve that keeps stomach acid down. In a hiatus hernia, that opening has stretched, and part of the stomach slides up through it into the chest.
The consequences follow from the anatomy: the diaphragm can no longer reinforce the valve, the valve sits in the wrong place at the wrong pressure, and acid escapes upwards more easily. That is why hiatus hernia is the most common structural cause of acid reflux — and why treating the reflux usually solves the problem even though the hernia remains.
Sliding vs rolling: the two types
Sliding hiatus hernia (over 90%)
The junction between oesophagus and stomach slides up through the hiatus, often moving up and down with swallowing and position. This is the common type, the reflux-causing type, and almost always the benign type.
Rolling (para-oesophageal) hernia
The junction stays put, but part of the stomach rolls up through the hiatus alongside the oesophagus. Rarer, and taken more seriously: the herniated portion can occasionally become trapped, so these are monitored and sometimes repaired even without symptoms.
Symptoms — and the many people with none
Most hiatus hernias are silent, discovered incidentally during an endoscopy or scan done for something else. No symptoms, no treatment needed. When symptoms do occur, they are essentially the symptoms of reflux:
- Heartburn — burning behind the breastbone, especially after meals or lying down
- Regurgitation — food or sour fluid coming back up unusually easily
- Discomfort or fullness after even modest meals
- Burping and bloating more than usual
- A sour taste in the mouth, or bad breath
- Occasionally: difficulty swallowing, hiccups, or chest discomfort after eating
Chest pain warning: hiatus hernia discomfort and cardiac pain can occupy the same territory. Chest pain with breathlessness, sweating, or pain spreading to arm, neck or jaw is 999 territory — read our guide to heart attack vs heartburn.
How it causes acid reflux and GORD
The lower oesophageal sphincter works as a team with the diaphragm: muscle valve inside, muscular collar outside. A hiatus hernia separates the team — the valve moves up into the chest while the collar stays below — and each then leaks a little. Add the small pouch of stomach above the diaphragm acting as an acid reservoir, and reflux becomes both more frequent and harder to clear. People with a hiatus hernia are therefore over-represented among those with GORD, night-time symptoms and oesophagitis — though plenty have a hernia and no reflux at all.
How it’s diagnosed
There is no way to feel a hiatus hernia from the outside. It is usually identified during endoscopy (a camera examination of the oesophagus and stomach, often arranged for persistent reflux), on a barium swallow X-ray series, or incidentally on a CT scan. If your reflux is well controlled, finding a sliding hernia rarely changes anything — it explains the symptoms rather than adding new problems.
Treatment: manage the reflux, not the hernia
The counterintuitive rule of hiatus hernia care: the hernia itself is usually left alone. Treatment aims at the acid and the pressure:
1
Control the acid with a PPI
A once-daily proton pump inhibitor such as omeprazole suppresses acid production so that any reflux that does occur no longer burns. Many people with a hiatus hernia take a PPI long term at the lowest effective dose, with annual review.
2
Reduce the upward pressure
Smaller meals (the single most useful change with a hernia), weight loss if you carry weight around the middle, no meals within 3 hours of bed, and avoiding tight waistbands and heavy lifting straight after eating.
3
Fix the nights
Raise the bed-head 10–20cm and favour left-side sleeping — the full playbook is in our night-time reflux guide.
4
Add rescue treatment as needed
An alginate such as Gaviscon after meals and at bedtime is particularly logical with a hernia — the raft sits exactly where the leak is. Trigger foods are the same as for reflux generally; see foods to avoid.
When surgery is considered
Surgery — usually keyhole (laparoscopic) fundoplication, in which the top of the stomach is wrapped around the lower oesophagus to rebuild the valve, with the hernia pulled back below the diaphragm and the hiatus tightened — is reserved for a minority: large rolling hernias (because of the trapping risk), reflux that genuinely fails optimised medical treatment, or people who cannot tolerate long-term medication. It is effective but not trivial, with side effects such as difficulty belching and early fullness, so the decision is made with a specialist after proper assessment.
Living with a hiatus hernia
For most people the diagnosis changes little: it names the cause of their reflux and points treatment in the right direction. The habits that matter are the ones above — portion size, weight, meal timing, night positioning — sustained rather than perfect. See a GP promptly if you develop difficulty swallowing, food sticking, unintentional weight loss, vomiting blood or black stools: these need investigation whatever the known diagnosis.
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Is a hiatus hernia serious?
Usually not. Sliding hiatus hernias — over 90% of cases — are common, especially over 50, and mostly cause either no symptoms or manageable reflux. The rarer rolling (para-oesophageal) type deserves closer attention because part of the stomach can become trapped, which is why rolling hernias are monitored and sometimes repaired even when quiet.
Can a hiatus hernia go away on its own?
No — once part of the stomach has slipped through the diaphragm, it does not move back permanently on its own. But that matters less than it sounds: most hiatus hernias cause no symptoms, and where they do, the reflux they provoke can almost always be controlled with medication and lifestyle changes, without the hernia itself ever needing repair.
What should I not eat with a hiatus hernia?
The same triggers as for acid reflux generally: large meals top the list, followed by fatty and fried food, chocolate, mint, alcohol, coffee and fizzy drinks. Meal size matters even more with a hiatus hernia than with ordinary reflux, because part of the stomach sits in the chest where a big meal presses upwards more directly.
Can a hiatus hernia be fixed without surgery?
In most cases, yes — not by shrinking the hernia but by controlling its consequences. A daily PPI controls the reflux, while weight loss, smaller meals and raising the bed-head reduce the pressure driving symptoms. Surgery (usually keyhole fundoplication) is reserved for large or rolling hernias and for reflux that fails proper medical treatment.
How do I know if I have a hiatus hernia?
You cannot feel the hernia itself — suspicion comes from the pattern: persistent reflux, food or fluid coming back up easily, and discomfort or fullness after modest meals. It is confirmed by endoscopy (often found incidentally during reflux investigations), a barium swallow X-ray, or sometimes a CT scan.
Treatment from Access Doctor
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Omeprazole
The UK’s most prescribed PPI — once-daily, 24-hour acid suppression.
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Lansoprazole
A fast-acting alternative PPI, including an orodispersible option.
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Esomeprazole
A stronger option for severe or persistent reflux symptoms.
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Start consultation →References
- NHS. Hiatus hernia. 2023. nhs.uk
- National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (CG184). 2019. nice.org.uk
- Hyun JJ, Bak YT. Clinical significance of hiatal hernia. Gut and Liver. 2011. pubmed.ncbi.nlm.nih.gov
- Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Practice & Research Clinical Gastroenterology. 2008. pubmed.ncbi.nlm.nih.gov
- Royal College of Surgeons of England. Laparoscopic anti-reflux surgery patient information. rcseng.ac.uk
Medical disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional for diagnosis and treatment. In a medical emergency, call 999.