A hernia in the stomach, known as a hiatal hernia, happens when the upper part of your stomach pushes upward through the diaphragm into your chest cavity. The diaphragm is the thin sheet of muscle separating your chest from your abdomen, and it has a small opening (called the hiatus) where your esophagus passes through to connect to your stomach. When that opening stretches or weakens, part of the stomach can slide through it. This is one of the most common structural problems in the digestive system, and it becomes significantly more likely as you age.
What Happens Inside Your Body
Your diaphragm normally acts as a barrier that helps keep stomach acid where it belongs. When part of the stomach migrates upward through the hiatus, that barrier is compromised. Acid flows more easily into the esophagus, which is why heartburn and acid reflux are the hallmark symptoms. The amount of stomach that pushes through can range from a small bulge to, in rare cases, nearly the entire organ sitting in the chest cavity.
Types of Hiatal Hernias
There are four recognized types, though most people have the first.
- Type I (sliding hernia): The junction where the esophagus meets the stomach slides up and down through the diaphragm. This is the most common type by far and often causes no symptoms at all.
- Type II (paraesophageal hernia): The junction stays in its normal position below the diaphragm, but a portion of the stomach’s upper curve (the fundus) squeezes up beside the esophagus. This type is less common but carries more risk of complications.
- Type III: A combination of Types I and II, where both the junction and the fundus push through the opening.
- Type IV: Other organs besides the stomach, such as the colon or spleen, migrate into the chest cavity alongside the stomach. This is the rarest and most serious type.
Who Gets Hiatal Hernias
Age is the strongest risk factor. A large study tracking thousands of adults found that hiatal hernia prevalence climbs steadily over the decades: about 2.4% of people in their 50s have one, rising to 7% in their 60s, 14% in their 70s, and nearly 17% by the time people reach their 80s and 90s. The muscles and connective tissue around the diaphragm naturally weaken over time, which explains the steep increase.
Body weight plays a significant role too. Higher BMI, larger waist circumference, and central obesity are all associated with both developing a hiatal hernia and having it grow larger over time. In one 10-year follow-up, the average hernia nearly doubled in size (from about 10 cm² to 18 cm²), and hernias that shrank or resolved on their own were found in people with a notably lower average BMI (around 27) compared to those whose hernias grew (average BMI around 30). Smoking and height are also linked to higher risk.
Symptoms and What They Feel Like
Many small hiatal hernias produce no symptoms at all and are discovered incidentally during imaging for something else. When symptoms do appear, they typically involve acid reflux: a burning sensation behind the breastbone, regurgitation of food or sour liquid, and difficulty swallowing. You might also notice chest pain, bloating after meals, or a feeling of fullness that comes on quickly when eating.
Larger hernias, especially paraesophageal types, can cause more pronounced problems. Some people experience shortness of breath because the herniated stomach presses against the lungs. Others develop anemia over time from small amounts of bleeding where the stomach rubs against the diaphragm.
When a Hernia Becomes Dangerous
The most serious complication is gastric volvulus, where the herniated stomach twists on itself. This can cut off blood supply and is a medical emergency. The classic warning signs are severe upper abdominal pain, retching without being able to vomit, and the sensation that something is seriously wrong. This triad of symptoms appears in roughly 70% of acute cases.
Intrathoracic volvulus (when the twist happens in the chest) can mimic a heart attack, causing sharp chest pain that radiates to the left side of the neck, shoulder, and arm. Strangulation and tissue death occur in 5% to 28% of cases involving a particular type of twist, so severe, sudden symptoms in someone with a known large hiatal hernia warrant emergency care.
A chronic, partial twist is also possible. People with this form tend to experience recurring episodes of upper abdominal pain, early fullness during meals, difficulty swallowing, and chest discomfort that comes and goes over weeks or months.
How Hiatal Hernias Are Diagnosed
A barium swallow is the preferred imaging test. You drink a chalky liquid that coats your digestive tract, then X-rays are taken as it moves through. The test is typically done while you lie on your stomach, which makes a sliding hernia easier to spot. If the junction between your esophagus and stomach sits more than 1 to 2 centimeters above the diaphragm on imaging, a sliding hiatal hernia is confirmed. Upper endoscopy, where a thin camera is passed down your throat, can also reveal a hernia and check for related damage like inflammation of the esophagus.
Managing Symptoms Without Surgery
Most hiatal hernias, particularly the common sliding type, are managed with lifestyle changes and sometimes medication. The goal is reducing acid reflux, since the hernia itself often isn’t the problem so much as the acid exposure it allows.
Eating smaller, more frequent meals instead of two or three large ones makes a noticeable difference for many people. After eating, wait at least two to three hours before lying down, and skip late-night snacks. Common trigger foods to limit or avoid include chocolate, mint, alcohol, spicy foods, high-fat foods, pepper, and caffeinated drinks like coffee, tea, colas, and energy drinks.
If nighttime heartburn is a problem, raising the head of your bed 15 to 20 centimeters (about 6 to 8 inches) helps. Use bed frame risers or a foam wedge under your mattress. Stacking extra pillows does not work because your body bends at the waist rather than staying on an incline, which can actually worsen reflux. Losing weight, if you carry excess weight, may slow hernia progression and improve symptoms based on the BMI data from long-term studies.
When Surgery Is Recommended
Surgery is typically reserved for large paraesophageal hernias that risk twisting, hernias causing severe symptoms that don’t respond to other treatments, or cases with complications like bleeding or obstruction. The most common procedure wraps the upper part of the stomach around the lower esophagus to reinforce the valve and pull the stomach back below the diaphragm.
The operation is usually done laparoscopically through small incisions. Immediately afterward, you’ll be limited to liquids, then gradually add soft foods over the first few days as directed by your surgeon. Lifting is restricted to nothing heavier than about 8 to 10 pounds (roughly a gallon of milk) for two weeks. Most people feel ready to return to desk work within one to two weeks, though physical jobs may require light-duty restrictions until a follow-up appointment.
About 10% of people who have this surgery eventually need a second procedure because symptoms return. Common long-term side effects include bloating, difficulty vomiting (because the wrap tightens the valve), and some trouble swallowing. These side effects often improve over the first few months as swelling resolves and the body adjusts.