A hiatal hernia (HH) is a common anatomical change, particularly in older adults, where a portion of the stomach protrudes upward into the chest cavity. While symptoms are typically centered in the chest and upper abdomen, discomfort in the middle of the back can occur. This relationship between a stomach issue and posterior pain is often misunderstood, yet it represents a real physiological connection. This connection is best understood by examining the nerves that relay sensation from the internal organs to the brain.
Understanding the Hiatal Hernia and Typical Symptoms
A hiatal hernia occurs when the upper part of the stomach pushes through the diaphragm, the large muscle separating the chest and abdominal cavities. The diaphragm has a natural opening, called the hiatus, through which the esophagus passes to connect with the stomach. If the surrounding muscle tissue weakens, this opening can widen, allowing a segment of the stomach to slide upward.
There are two primary types: the sliding hernia, where the junction between the esophagus and stomach moves up and down, and the less common paraesophageal hernia, where a portion of the stomach pushes up alongside the esophagus. Common symptoms are localized to the chest and upper abdomen, often resulting from the backflow of stomach acid into the esophagus (reflux). This causes the familiar burning sensation called heartburn, regurgitation, and sometimes difficulty swallowing.
How a Hiatal Hernia Can Lead to Middle Back Pain
While hiatal hernia pain is usually felt in the front, it can cause discomfort perceived in the middle or upper back due to referred pain. Referred pain is visceral pain originating in an internal organ that the brain interprets as coming from a different area of the body. This misinterpretation occurs because internal organs and the skin/muscles in the thoracic region share common nerve pathways traveling to the spinal cord.
The vagus nerve, extending from the brainstem to the abdomen, and the phrenic nerve, supplying the diaphragm, are both implicated. When the stomach or esophagus is irritated by acid or the hernia’s physical presence, signals travel along these nerves. The phrenic nerve shares sensory pathways that also supply the neck, shoulder, and upper back, allowing diaphragm irritation to be perceived in the thoracic spine. A large hernia can also create direct pressure on the diaphragm, triggering a visceral-somatic reflex that causes muscular and joint pain in the back.
Other Common Reasons for Middle Back Discomfort
Middle back pain is a common complaint, and a hiatal hernia is only one possible cause among many. Musculoskeletal issues are the most frequent culprits, often stemming from poor posture, prolonged sitting, or improper lifting techniques that strain the thoracic spine’s muscles and ligaments. This type of discomfort is usually localized and worsens with specific movements.
Back pain can also signal structural problems within the spine, such as a herniated disc, degenerative disc disease, or spinal stenosis, which can compress nerves and lead to radiating pain. Pain referred to the mid-back can also originate from other abdominal or pelvic organs. Conditions like kidney stones, kidney infections, or inflammation of the pancreas (pancreatitis) frequently cause intense pain felt in the flank or back. Distinguishing between these causes requires a medical evaluation to determine the true source of the discomfort.
When to Consult a Healthcare Provider
Any persistent or worsening pain in the middle of the back, especially if it coincides with digestive symptoms, warrants a medical consultation. A healthcare provider can determine if the pain is musculoskeletal or referred from an internal issue like a hiatal hernia. Diagnosis commonly involves imaging tests like a barium swallow, where the patient drinks a contrast liquid to make the esophagus and stomach visible on an X-ray. An upper endoscopy, which uses a flexible tube with a camera, may also be used to visualize the stomach and esophagus directly.
Immediate medical attention is necessary if back pain is accompanied by “red flag” symptoms suggesting a severe complication. These include sudden, severe chest pain, vomiting blood or passing black, tarry stools, or an inability to pass gas or have a bowel movement. These could indicate a strangulated hernia or gastrointestinal bleeding. For less acute but concerning symptoms, such as unexplained weight loss, difficulty swallowing, or chronic pain that does not respond to over-the-counter treatment, professional evaluation is the correct next step.