Hiatal hernia

What is a hiatal hernia?

A hiatal hernia happens when the top part of your stomach pushes upward into your chest through a natural opening in the diaphragm (the breathing muscle separating your chest from your belly).

Hiatal hernias are classified into four types:

• Type I, sliding hernia: the most common type. The top of your stomach slides up and down into your chest depending on your posture or belly pressure. It is a major cause of acid reflux and heartburn.

• Type II, true paraoesophageal hernia: the stomach-esophagus junction stays in place, but a pocket of the stomach pinches up next to it. This trapped tissue can twist or block food.

• Type III, mixed hernia: a combination of types I and II, where both the stomach junction and an extra pocket of the stomach push up into the chest together.

• Type IV, complex hernia: the most severe type, where the hernia is large enough that other belly organs, like the colon, small intestine, or spleen, slide into the chest alongside the stomach.

Types II, III, and IV are collectively referred to as paraoesophageal hernias and carry a higher risk of serious complications including gastric volvulus, obstruction, and ischaemia.

Symptoms of hiatal hernias

Symptoms vary significantly between sliding and paraoesophageal hernias. Many hiatal hernias, particularly small sliding hernias, cause no symptoms and are discovered entirely incidentally.

Sliding hiatal hernia:

• Heartburn and acid reflux, typically worse after meals, when lying flat, or bending forward

• Regurgitation of acid or food into the mouth or throat

• A sour or bitter taste, particularly on waking

• Belching and bloating

• Chest discomfort or non-cardiac chest pain

• Difficulty swallowing (dysphagia), particularly with large meals

Paraoesophageal hernia:

• Chest pain or pressure, particularly after eating

• Dysphagia and a sensation of food becoming stuck in the chest

• Early satiety and nausea from gastric compression

• Shortness of breath can occur with a large hernia that occupies substantial space within the chest

• Anaemia can occur when chronic bleeding develops from gastric mucosal lesions, such as Cameron lesions, within a large hiatal hernia

• In severe cases: gastric volvulus causing sudden severe chest pain, vomiting, and inability to swallow, a surgical emergency

Important: Sudden severe chest pain with inability to swallow or vomit may indicate gastric volvulus, a surgical emergency requiring immediate medical attention.

What causes hiatal hernias?

Hiatal hernias develop from a combination of structural weakness of the hiatus and increased intra-abdominal pressure. Contributing causes include:

• Age-related weakening of the diaphragmatic hiatus the most common underlying factor, as the phrenico-oesophageal ligament that anchors the gastro-oesophageal junction weakens progressively with age

• Obesity excess abdominal fat significantly increases intra-abdominal pressure, pushing abdominal contents upward through the hiatus

• Chronic increased intra-abdominal pressure from persistent coughing, straining during defecation, heavy lifting, or chronic constipation

• Pregnancy the growing uterus displaces abdominal contents and increases intra-abdominal pressure

• Connective tissue disorders including Ehlers-Danlos syndrome and Marfan syndrome weaken the ligamentous supports of the gastro-oesophageal junction

• Previous oesophageal or gastric surgery can alter the normal anatomy and predispose to hiatal hernia development

• Congenital factors some individuals have a constitutionally wider hiatus predisposing to hernia formation

How is a hiatal hernia detected?

Hiatal hernias are detected through thoracic and abdominal imaging, with blood tests assessing complications and associated conditions.

Thoracic and Abdominal MRI Elfcare’s full body MRI images the chest and abdomen and can identify a hiatal hernia if one is present, along with a general sense of its size and whether other organs have moved into the chest alongside the stomach. If a hernia is found, particularly one that looks like it may be a paraoesophageal type or shows signs of twisting, we arrange the appropriate follow-up, such as a barium swallow, endoscopy, or targeted CT, to confirm the type and guide treatment.

Blood tests cannot detect hiatal hernias directly but assess complications and conditions most commonly associated with their consequences. Relevant markers in Elfcare's panel include:

• Haemoglobin and ferritin anaemia from chronic occult bleeding from herniated gastric mucosa is a complication of paraoesophageal hernias, particularly Cameron lesions within the hernia sac

• Albumin low albumin from poor nutritional intake due to dysphagia or early satiety in symptomatic hiatal hernia

• TSH thyroid dysfunction causes gastrointestinal motility changes that can worsen reflux symptoms associated with hiatal hernia

Why early detection matters

For sliding hiatal hernias, early identification explains long-standing reflux symptoms and enables appropriate management with dietary modification, lifestyle change, and proton pump inhibitor therapy, preventing the progressive oesophageal mucosal damage from chronic acid reflux that, over years, can lead to Barrett's oesophagus and oesophageal adenocarcinoma. For paraoesophageal hernias, early identification allows for elective surgical repair before the serious complications of gastric volvulus or strangulation occur, which carry significantly higher surgical risk when performed as emergency procedures. Identifying anaemia from chronic Cameron lesions in a paraoesophageal hernia, before it has become clinically significant, allows for timely surgical intervention that resolves the bleeding source.

How Elfcare can help

Elfcare's full body MRI covers the thorax and abdomen as standard, imaging the diaphragm and gastro-oesophageal junction, and can identify a hiatal hernia as an incidental finding. For a condition that is frequently present for years without formal diagnosis, this gives you and your doctor a starting point.

Our blood panel covers haemoglobin, ferritin, albumin, and metabolic markers, identifying anaemia from chronic bleeding and the metabolic risk factors most closely associated with hiatal hernia development and symptom severity.

If our MRI or blood tests identify a hiatal hernia or related findings, we take care of further diagnostics or refer you to the appropriate specialist.