A hiatal hernia can cause difficulty swallowing, a symptom medically known as dysphagia. This common condition involves a portion of the stomach pushing up through the diaphragm, the large muscle separating the chest and abdominal cavities. While many individuals have no symptoms, the displacement of the stomach can interfere with the normal mechanics of swallowing, leading to noticeable difficulty or discomfort. Dysphagia, the impeded passage of food or liquid from the mouth to the stomach, often indicates the hernia is large enough to be functionally significant.
Understanding the Hiatal Hernia
The diaphragm contains a small opening called the esophageal hiatus, through which the esophagus passes to connect with the stomach. A hiatal hernia develops when the upper part of the stomach slides or bulges upward through this hiatus into the chest cavity. This condition is common, especially in people over 50, and is classified into two main types based on how the stomach moves.
The most frequent form is the sliding hiatal hernia (Type I), accounting for up to 95% of cases. This occurs when the junction between the esophagus and the stomach, along with a segment of the stomach, slides up and down through the hiatus. The second major category is the paraesophageal hernia. In this less common but potentially more serious type, the stomach junction remains in place, but a portion of the stomach rolls up alongside the esophagus into the chest.
The Direct Link: Why Swallowing Becomes Difficult
Difficulty swallowing associated with a hiatal hernia stems from two distinct physiological mechanisms: chronic inflammation and structural obstruction. The hernia often compromises the function of the lower esophageal sphincter, the muscular ring that prevents stomach contents from backing up. This malfunction allows stomach acid and digestive juices to reflux into the esophagus, leading to gastroesophageal reflux disease (GERD).
Chronic acid exposure irritates the esophageal lining, causing inflammation known as esophagitis. Over time, this inflammation can result in scar tissue formation, narrowing the esophageal passageway into a stricture. When the esophagus diameter is reduced, the food bolus can become temporarily stuck or pass with effort, resulting in dysphagia. This acid-induced narrowing is a frequent cause of swallowing issues, particularly with a sliding hiatal hernia.
The second mechanism involves the physical presence of the herniated stomach tissue, especially in larger hernias. The portion of the stomach protruding into the chest cavity mechanically presses against the lower esophagus. This pressure creates a functional obstruction, physically impeding the movement of food. The food bolus may struggle to pass the point where the stomach is bulging up, causing extrinsic compression.
Diagnosing the Condition and Next Steps
Identifying a hiatal hernia as the cause of dysphagia requires specific medical investigation to rule out other conditions.
A common initial tool is a barium swallow, also known as an esophagram or Upper GI series. During this X-ray procedure, the patient swallows a liquid contrast material that coats the esophagus and stomach. This allows the radiologist to visualize the hernia’s size and how it affects the swallowing process in real-time.
Another frequent diagnostic test is an upper endoscopy, or esophagogastroduodenoscopy (EGD). This procedure involves passing a thin, flexible tube with a camera down the throat to directly examine the lining of the esophagus and stomach. An endoscopy assesses the size of the hernia, identifies signs of esophagitis, and detects strictures or structural damage caused by chronic acid reflux.
Esophageal manometry may also be used to measure the pressure and coordination of the esophageal muscles during swallowing. This test helps determine if the difficulty is due to muscle weakness or a functional obstruction rather than inflammation. Seek medical attention if dysphagia is persistent, accompanied by pain, unexplained weight loss, or the feeling that food is consistently getting stuck.
Management and Treatment Options
Treatment for hiatal hernia-related dysphagia typically begins with conservative measures focused on reducing acid reflux and minimizing pressure on the diaphragm. Lifestyle modifications are the first line of defense, including eating smaller, more frequent meals to reduce stomach volume. Avoiding trigger foods such as fatty or spicy items, chocolate, and caffeine can also help decrease acid production.
Pharmacological treatments aim to reduce the acidity of stomach contents, making reflux less damaging to the esophagus. These medications include antacids for immediate relief, H2-receptor blockers, and proton pump inhibitors (PPIs) for stronger, longer-lasting acid suppression. Elevating the head of the bed by six to eight inches prevents nocturnal reflux using gravity.
For severe symptoms, cases unresponsive to medication, or if the hernia is a paraesophageal type with complication risk, surgical repair may be considered. A common procedure is a laparoscopic Nissen fundoplication. This involves pulling the stomach back into the abdominal cavity and wrapping the upper part of the stomach around the lower esophagus. This maneuver reinforces the weakened lower esophageal sphincter and tightens the diaphragmatic hiatus, preventing both reflux and mechanical obstruction.