A hiatal hernia occurs when the upper part of the stomach pushes up through the small opening, called the hiatus, in the diaphragm muscle that separates the abdomen and chest. Affecting approximately 20% of the general population, it becomes more frequent with age, reaching 50% to 60% in individuals over 50. While many small hernias are asymptomatic, larger ones often lead to symptoms like chronic heartburn and regurgitation due to acid reflux. Treatment for a symptomatic hiatal hernia typically depends on the severity and type of the hernia, progressing from conservative management to surgery if needed.
The First Point of Contact and Initial Assessment
The healthcare journey for a suspected hiatal hernia typically begins with a Primary Care Physician (PCP) when patients seek consultation for common symptoms such as persistent heartburn, regurgitation, or upper abdominal discomfort. The PCP’s role involves a thorough physical examination and detailed history to understand the nature of the symptoms and to rule out other possible causes of chest pain or indigestion.
During this initial assessment, the PCP may order preliminary diagnostic studies to visualize the upper digestive tract. A barium swallow X-ray, which involves the patient drinking a chalky liquid, is a common initial test that outlines the esophagus and stomach, making the hernia visible. If symptoms are mild, the PCP may start a trial of antacid medications. If symptoms are severe, unresponsive to initial treatment, or suggest a larger anatomical issue, the PCP will refer the patient to a digestive system specialist for management.
Specialists Focused on Medical Management
The specialist who manages the majority of non-surgical hiatal hernias is the Gastroenterologist (GI). The GI uses advanced diagnostic tools to characterize the hernia and its effects on the esophagus. Upper endoscopy (EGD) is performed to visually inspect the hernia size and check for complications like inflammation (esophagitis) or tissue changes such as Barrett’s esophagus.
Specialized functional tests confirm the extent of the disease. Esophageal manometry measures muscular contractions and pressure within the esophagus, ensuring it can move food effectively, which is necessary before considering surgery. A 24-hour pH monitoring test quantifies acid exposure in the esophagus, confirming if the reflux is pathological and contributing to symptoms.
Management for the most common type of hiatal hernia, the sliding hernia, is primarily medical and focuses on controlling acid reflux. Gastroenterologists prescribe acid-suppressing medications, most notably Proton Pump Inhibitors (PPIs), which block the enzyme system that produces stomach acid. H2-receptor blockers are also used, often to manage nighttime symptoms.
These pharmaceutical treatments are paired with specific lifestyle modifications. These include elevating the head of the bed, losing weight to reduce intra-abdominal pressure, and avoiding trigger foods like caffeine, alcohol, and fatty items.
Surgical Teams and When They Become Necessary
When medical management fails to control severe symptoms or when the hernia poses a risk, the patient is referred to a General Surgeon or a Thoracic Surgeon. Surgery is considered for patients with persistent, severe gastroesophageal reflux disease (GERD) unresponsive to medication, or for those with specific hernia types. Large paraesophageal hernias (Type II, III, and IV), where a significant portion of the stomach is rolled up next to the esophagus, often require repair due to the risk of life-threatening complications like strangulation, incarceration, or gastric volvulus.
The primary goal of the operation is to pull the herniated stomach tissue back into the abdominal cavity and to narrow the widened hiatus opening in the diaphragm, a procedure called hiatoplasty. The most common surgical procedure is the Laparoscopic Nissen Fundoplication, a minimally invasive technique where the surgeon wraps the upper part of the stomach (the fundus) 360 degrees around the lower esophagus. This wrap creates a new valve mechanism to prevent the backflow of acid. If preoperative testing shows poor esophageal motility, a partial wrap, such as a Toupet (270-degree) fundoplication, may be chosen to reduce the risk of postoperative swallowing difficulty.
Long-Term Monitoring and Ancillary Care
After diagnosis or treatment, continued management involves long-term surveillance by the Gastroenterologist and the Primary Care Physician. For patients managed medically, the GI specialist monitors the effectiveness of acid suppression and periodically checks for complications like esophagitis or hernia enlargement through repeat endoscopy. Following surgical repair, the surgical team and GI specialist coordinate follow-up to monitor for hernia recurrence or any new swallowing issues.
Ancillary care providers, particularly Registered Dietitians (RDs), assist in symptom management and recovery. RDs provide personalized guidance on dietary habits, helping patients identify specific food triggers that exacerbate reflux symptoms. Managing body weight is emphasized for all patients, as excess intra-abdominal pressure contributes to hernia development and recurrence. The dietitian’s expertise is also instrumental in ensuring proper nutrition during the post-operative period when patients must adhere to specific texture-modified diets to allow the surgical repair to heal properly.