A hiatal hernia occurs when a portion of the stomach pushes upward through a natural opening in the diaphragm, the large muscle separating the chest and abdominal cavities. Many people mistakenly expect to see an external lump or bulge on the skin, similar to an inguinal or umbilical hernia. This expectation is incorrect because the displacement happens entirely inside the body cavity. A hiatal hernia does not manifest as a visible change on the exterior of the chest or abdomen; its presence is felt, not seen.
Why Hiatal Hernias Are Not Visible
The lack of external visibility is due to the hernia’s specific anatomical location. The diaphragm contains a small opening called the esophageal hiatus, through which the esophagus passes to connect to the stomach. In a hiatal hernia, the upper part of the stomach slides or bulges through this hiatus and into the chest cavity.
This herniated tissue is situated deep within the torso, protected by the rib cage and the layers of muscle and skin. Unlike hernias that protrude through the abdominal wall, the hiatal hernia remains covered by surrounding skeletal structures. The protrusion occurs into the chest cavity, preventing any external manifestation.
The two most common types, the sliding hiatal hernia and the paraesophageal hernia, both involve internal movement. The sliding type accounts for the vast majority of cases, seeing the junction between the esophagus and stomach move up into the chest. The less common paraesophageal type involves a part of the stomach moving up alongside the esophagus. Recognition of the condition relies entirely on the physical sensations it causes internally.
The Symptoms You Should Look For
Since the condition is not visible, a person must pay attention to the internal sensations and discomfort it causes. The most frequent symptoms relate to the disruption of the natural barrier between the stomach and the esophagus, leading to gastroesophageal reflux disease (GERD). Heartburn is the most common complaint, manifesting as a burning sensation behind the breastbone, often worsening after meals or when lying down.
The displacement allows stomach acid and sometimes food to flow back up into the esophagus, a process called regurgitation. This results in a sour or bitter taste in the throat and mouth, particularly upon waking. Difficulty swallowing, termed dysphagia, may also occur, as the herniated tissue or inflammation from chronic acid exposure can narrow the esophageal pathway.
Larger hernias can produce noticeable symptoms due to the mechanical compression of the stomach. Individuals may experience early satiety, feeling full almost immediately after starting to eat, or pain in the upper abdomen or chest. In substantial cases, the stomach’s position can interfere with the diaphragm’s function, occasionally leading to shortness of breath or persistent coughing.
A very small hiatal hernia may be completely asymptomatic, often discovered incidentally during a medical procedure. Conversely, a large hernia, especially a paraesophageal type, can lead to severe issues. These issues include chronic blood loss, which may present as anemia or black stools.
How Doctors Identify the Condition
Because a hiatal hernia cannot be visually inspected from the outside, doctors rely on internal imaging and specialized tests to confirm the diagnosis. The most common initial diagnostic tool is the Barium Swallow X-ray, also known as an Upper GI Series. The patient drinks a liquid containing barium, which coats the lining of the upper digestive tract. This allows the physician to observe the stomach’s position relative to the diaphragm and determine the size of the herniation.
Another frequently used procedure is an upper endoscopy, where a thin, flexible tube equipped with a camera, called an endoscope, is passed down the throat. Endoscopy provides a direct, high-resolution visual of the esophagus and stomach. This helps identify the hernia and check for related complications like inflammation or tissue damage.
In some cases, a physician may order additional functional tests to assess the impact of the hernia. Esophageal manometry measures the strength and coordination of muscle contractions in the esophagus. A pH monitoring test measures the amount of acid refluxing into the esophagus over time. These tests provide important physiological data that help confirm the presence of a hiatal hernia and guide the appropriate treatment plan.