A hiatal hernia occurs when a portion of the stomach pushes up into the chest cavity through an opening in the diaphragm. While heartburn and regurgitation are the most recognizable symptoms, a persistent, unexplained cough can also be a frequent manifestation of this gastrointestinal issue. Understanding the mechanics of a hiatal hernia clarifies why a stomach problem can lead to a chronic cough.
Defining the Hiatal Hernia
A hiatal hernia involves the abnormal protrusion of tissue through a weakness in the surrounding muscle barrier. The stomach pushes through the esophageal hiatus, the opening in the diaphragm normally reserved for the esophagus. The diaphragm separates the chest cavity from the abdomen, and widening the hiatus allows the upper part of the stomach to enter the chest.
Hiatal hernias are categorized into two main types. The most frequent is the sliding hiatal hernia (Type 1), accounting for up to 95% of cases. This type occurs when the junction where the esophagus meets the stomach slides up and down through the hiatus. Since the sliding type displaces the lower esophageal sphincter (LES), it is strongly associated with reflux symptoms.
The less common categories, known as paraesophageal hernias (Types 2 through 4), involve a part of the stomach rolling up next to the esophagus. These types are generally less likely to cause acid reflux because the gastroesophageal junction remains below the diaphragm. The sliding motion in the Type 1 hernia directly interferes with the body’s natural anti-reflux mechanisms.
The Physiological Link to Persistent Cough
The connection between a hiatal hernia and a persistent cough is mediated by gastroesophageal reflux disease (GERD). When the upper stomach slides above the diaphragm, the pressure barrier is compromised. This displacement prevents the lower esophageal sphincter from closing tightly, allowing acidic stomach contents to flow back into the esophagus.
This backflow, or reflux, triggers a cough through two primary pathways.
Esophago-Bronchial Reflex
Acid irritates sensory nerve endings in the lower esophagus. This irritation signals the brainstem via the vagus nerve, triggering a reflex cough as a protective mechanism, even if acid does not reach the throat. The cough is usually dry, non-productive, and often worsens when lying down, especially after eating.
Laryngopharyngeal Reflux (LPR)
LPR, sometimes called “silent reflux,” occurs when the refluxate travels over the upper esophageal sphincter, reaching the voice box (larynx) and the back of the throat (pharynx). These tissues are far more sensitive to acid and the digestive enzyme pepsin than the esophagus lining. This micro-aspiration and direct irritation of the upper airways causes throat clearing, hoarseness, and a chronic cough.
In patients with LPR, heartburn is frequently absent, making the underlying cause of the cough difficult to diagnose. Acid infusion into the distal esophagus increases the sensitivity of the cough reflex, correlating reflux events with coughing frequency. The cough is a reaction to the chemical irritation caused by stomach contents contacting respiratory tissues.
Strategies for Symptom Relief
Managing the chronic cough associated with a hiatal hernia focuses on controlling the underlying acid reflux. Simple lifestyle adjustments significantly reduce the frequency of reflux episodes. Eating smaller, more frequent meals prevents the stomach from becoming overly full and pressuring the hiatus. Avoid lying down for a minimum of two to three hours after consuming food.
Specific dietary modifications help lower stomach acid production and reduce irritation. Common trigger foods that should be limited include:
- Citrus fruits
- Tomatoes
- Chocolate
- Peppermint
- Caffeine
- High-fat or spicy meals
Maintaining a moderate body weight also relieves abdominal pressure, lessening the upward pushing of the stomach through the diaphragm opening.
Positional changes during sleep are an effective strategy for symptom relief. Elevating the head of the bed by six to eight inches using blocks or a wedge pillow utilizes gravity to keep stomach contents from flowing back into the esophagus. Adding extra pillows is often ineffective, as it only raises the head and not the entire torso.
Over-the-counter medications provide temporary relief by neutralizing or reducing stomach acid. Antacids offer immediate neutralization, while H2 blockers and proton pump inhibitors (PPIs) decrease acid production over a longer period. For a persistent cough or symptoms that do not improve, consultation with a physician is necessary. A healthcare provider can prescribe stronger medications or perform diagnostic tests to confirm the hernia and rule out other respiratory causes.