A hiatal hernia occurs when a portion of the stomach pushes up through the diaphragm, and difficulty swallowing, medically termed dysphagia, is a common consequence. The diaphragm is a large, dome-shaped muscle that separates the chest cavity from the abdomen, containing a small opening called the hiatus through which the esophagus passes to connect with the stomach. When a hiatal hernia develops, it disrupts the normal function of the digestive tract, and this disruption can directly or indirectly lead to problems with swallowing.
Anatomy of a Hiatal Hernia
A hernia describes any situation where an internal organ or tissue pushes through the wall of the cavity that normally contains it. In the case of a hiatal hernia, the stomach pushes up through the esophageal hiatus into the chest cavity. This opening becomes widened, permitting the stomach to protrude.
The vast majority of cases involve a Type 1 or “sliding” hiatal hernia. In this type, the section of the esophagus that joins the stomach, known as the gastroesophageal junction, slides up and down into the chest through the hiatus. This movement is often temporary and can be provoked by increased abdominal pressure.
The less common forms, known as paraesophageal hernias, involve the stomach bulging up into the chest alongside the esophagus. These paraesophageal types can be more concerning because the herniated stomach tissue is at a higher risk of becoming trapped, twisted, or having its blood supply cut off.
Why Swallowing Becomes Difficult
Difficulty swallowing related to a hiatal hernia is typically an indirect result of the anatomical change, often arising from chronic inflammation. The hernia compromises the function of the lower esophageal sphincter (LES), the ring of muscle that acts like a valve separating the esophagus and the stomach. When this valve is weakened or displaced by the herniation, stomach acid and digestive contents back up into the esophagus, a process known as gastroesophageal reflux disease (GERD).
Chronic exposure to stomach acid irritates the sensitive lining of the esophagus, causing inflammation known as esophagitis. This irritation and subsequent healing process can eventually lead to the formation of scar tissue. As this scar tissue builds up, it causes the esophagus to narrow, creating a benign esophageal stricture. This physical narrowing obstructs the normal passage of swallowed food and liquid, which is a common cause of dysphagia in individuals with long-standing hiatal hernias and GERD.
The physical presence of the herniated stomach tissue can also mechanically interfere with the swallowing process. In larger hernias, the displaced stomach portion may physically compress the esophagus or cause it to twist. This mechanical compression directly impedes the downward movement of food, contributing to the sensation of difficulty swallowing. Dysphagia is recognized as becoming more frequent as the size of the hiatal hernia increases.
Treatment and Lifestyle Adjustments
Management of dysphagia associated with a hiatal hernia focuses primarily on reducing acid reflux and treating the resulting inflammation and narrowing. One of the first lines of defense involves specific lifestyle modifications aimed at minimizing the opportunity for acid reflux to occur. These adjustments include eating smaller, more frequent meals, which helps reduce the volume and pressure in the stomach.
It is also beneficial to avoid foods known to trigger heartburn, such as fatty or fried items, alcohol, caffeine, and chocolate, because they can weaken the lower esophageal sphincter. Patients should avoid lying down for three to four hours after eating. Elevating the head of the bed by six to eight inches can also prevent nocturnal reflux episodes.
Medical treatment often involves medications that reduce or neutralize stomach acid to allow the esophagus to heal. Over-the-counter antacids can offer quick, temporary relief by neutralizing acid, while H2-receptor blockers work to decrease acid production. Proton pump inhibitors (PPIs) are stronger medications that effectively block acid production and are frequently used to promote healing of the esophageal lining and resolve inflammation.
If dysphagia persists, or if the narrowing of the esophagus is severe, a healthcare provider may recommend further diagnostic testing, such as an endoscopy. In cases where a stricture is identified, a procedure called esophageal dilation can be performed to physically stretch the narrowed area and improve swallowing. For severe, non-responsive symptoms, or for hernias that pose a risk of complications like strangulation, surgical repair to return the stomach to the abdomen and tighten the hiatus may be considered.