A hiatal hernia occurs when a portion of the stomach protrudes upward through the diaphragm, the large muscle that separates the chest and abdominal cavities. This protrusion happens through an opening in the diaphragm called the hiatus, which the esophagus normally passes through. While many people with this condition experience no issues, the answer to whether a hiatal hernia can cause a persistent cough is yes, although the relationship is generally indirect. The physical presence of the hernia often creates conditions within the body that directly lead to the development of a chronic cough.
The Mechanism Linking Hernia to Chronic Cough
The cough associated with a hiatal hernia is typically a secondary symptom arising from gastroesophageal reflux disease, or GERD. The hernia compromises the function of the lower esophageal sphincter (LES), which is the muscular ring that acts as a valve between the esophagus and the stomach. When a section of the stomach slides above the diaphragm, the LES is no longer properly supported by the surrounding muscle, causing it to weaken and allow stomach contents to flow backward.
This backward flow, known as reflux, allows stomach acid, digestive enzymes, and sometimes bile to repeatedly irritate the lining of the esophagus. This irritation can trigger a reflex cough, often called a “reflux cough,” as the body attempts to clear the irritant. The chronic nature of the cough is maintained by the ongoing failure of the LES due to the hernia’s anatomical disruption.
In some cases, the reflux is “silent,” meaning the acidic contents travel all the way up to the throat and voice box, a condition known as Laryngopharyngeal Reflux (LPR). The delicate tissue of the larynx is far more sensitive to acid exposure than the esophageal lining, requiring very little reflux to cause significant irritation. This can result in a persistent, dry, and non-productive cough, often without the typical symptoms of heartburn.
The vagus nerve, which runs near the esophagus and controls many functions including the cough reflex, also plays a role in this mechanism. Acidic irritation in the lower esophagus can stimulate the sensory branches of the vagus nerve, which then sends signals to the brain that trigger a protective coughing response. This neural pathway, known as the esophago-bronchial reflex, can cause coughing even when the refluxate has not reached the upper airways.
Common Symptoms Associated with a Hiatal Hernia
While a chronic cough may be the most bothersome symptom, a hiatal hernia frequently presents with other signs related to the resulting acid reflux. The most common of these is heartburn, or pyrosis, which is a burning sensation felt in the chest, particularly after eating or when lying down. This feeling occurs as the stomach acid washes up into the lower esophagus.
Regurgitation is another frequent occurrence, which involves the effortless return of sour liquid or undigested food particles into the throat or mouth. This symptom is a direct result of the compromised LES function and the pooling of stomach contents above the diaphragm. Some individuals also report dysphagia, or difficulty swallowing, as the chronic acid exposure can cause inflammation and swelling in the esophageal lining.
The physical presence of the hernia may also lead to non-cardiac chest discomfort that can be sharp or dull, sometimes mimicking heart pain. This sensation can be caused by acid irritation, esophageal spasms, or even the pressure of the displaced stomach on the diaphragm. Understanding these accompanying symptoms provides a broader picture for a person to discuss with a healthcare provider.
Diagnostic Steps to Confirm the Cause
Confirming that a hiatal hernia is the root cause of a chronic cough involves a series of specialized diagnostic procedures to visualize the anatomy and measure acid exposure. One of the primary tools is an upper endoscopy, or esophagogastroduodenoscopy (EGD), where a thin, flexible tube with a camera is passed down the throat. This allows the physician to visually inspect the esophagus and stomach, confirm the presence and size of the hernia, and check for signs of inflammation or damage caused by reflux.
Another common test is the Barium swallow, also known as an Upper GI series, where the patient drinks a chalky liquid that coats the digestive tract. A series of X-rays are then taken, which clearly outline the shape and position of the esophagus and stomach, making it possible to see the protrusion of the stomach through the hiatus. This test is highly effective for identifying the size and type of hiatal hernia.
To definitively link the cough to reflux, a procedure called pH monitoring is often performed. This involves placing a small catheter or a wireless capsule, such as the Bravo capsule, in the esophagus for 24 to 96 hours to measure the frequency and duration of acid exposure. A positive correlation between episodes of acid reflux and reported coughing fits strongly suggests the hernia-induced reflux is the underlying trigger for the chronic cough.
Managing and Treating the Hernia-Related Cough
The management of a hernia-related cough focuses primarily on reducing the severity and frequency of the associated acid reflux. Initial treatment always begins with lifestyle modifications designed to minimize the upward movement of stomach contents.
Lifestyle Modifications
Simple changes, such as avoiding meals within three hours of bedtime and elevating the head of the bed by six to eight inches, can use gravity to prevent nocturnal reflux. Dietary adjustments are also important, often involving the avoidance of common reflux triggers like caffeine, alcohol, fatty foods, and peppermint. Achieving and maintaining a healthy weight helps reduce abdominal pressure, which can otherwise force the stomach further into the chest cavity and worsen the hernia.
Medication Therapy
Medication therapy is centered on reducing the amount of acid produced in the stomach to make any reflux less irritating. Proton pump inhibitors (PPIs), such as omeprazole or pantoprazole, are highly effective as they block the enzyme system responsible for acid secretion. H2 blockers, like famotidine, provide an alternative by reducing the amount of histamine that stimulates acid production.
Surgical Intervention
For severe cases where the cough and reflux are debilitating and do not respond to medication or lifestyle changes, surgical intervention may be considered. The standard surgical procedure is a Nissen fundoplication, where the upper part of the stomach is wrapped tightly around the lower esophagus to reinforce the LES. This procedure physically reconstructs the anti-reflux barrier, which can provide a long-term solution by correcting the underlying anatomical defect caused by the hiatal hernia.