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Diaphragmatic hernia (hiatus hernia) – causes, symptoms treatment

Diaphragmatic hernia (hiatus hernia) is a clinical picture that entails part of the stomach sliding through the diaphragm into the chest cavity. A diaphragmatic hernia often occurs in conjunction with heartburn and gastroesophageal reflux disease. It is assumed that up to 40 per cent of people over the age of 50 have a form of diaphragmatic hernia. Many of these patients do not suffer from any symptoms, however. What a diaphragmatic hernia is, how it develops and how it can be detected and treated, is explained below.

What is a diaphragmatic hernia?

A diaphragmatic hernia, referred to as hiatus hernia by physicians, is when part of the stomach slides through the diaphragm. It pushes through the opening for the esophagus (hiatus esophagus) and reaches the chest cavity. In most cases, only the upper part of the stomach is affected by the abnormal position. The vast majority of hiatus hernias occur in people aged 50 and above. Women are more likely to be affected by the disease than men are. The main risk factor for developing a diaphragmatic hernia is being overweight (obesity).

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How does a diaphragmatic hernia develop?

The diaphragm is the most important muscle in the respiratory structure. Furthermore, it separates the chest cavity, in which the lungs and heart are located, from the abdominal cavity, which contains organs such as the liver, kidneys and gastrointestinal tract. Three large openings in the diaphragm are designated as “hiatus” in each case. One opening enables the large vena cava to pass into the abdominal cavity, while the other accommodates the main artery (aorta). The gullet (esophagus) passes into the stomach via the last opening, which is located in the abdominal cavity.

If pressure increases in the abdominal cavity, it may result in the opening for the passage of the esophagus becoming instable. Even the ligaments that hold the esophagus to the opening may be damaged. When the diaphragm opening decreases in stability, part of the stomach may slide through the opening and reach the chest cavity. This phenomenon is then referred to as diaphragmatic hernia, or hiatus hernia.

Which types of hiatus hernia are there?

Physicians differentiate between three types of diaphragmatic hernias:

  • axial sliding hernia
  • paraesophageal hernia
  • hybrid forms

Illustration 1: different types of hiatus hernia

Axial sliding hernia

The axial sliding hernia is the most common form of hiatus hernia. Some 80 per cent of all diaphragmatic hernias constitute an axial sliding hernia. This type involves part of the stomach sliding along the esophagus into the chest cavity (axial), and represents a kind of extension of the esophagus before passing through the diaphragm.

Paraesophageal hernia

The paraesophageal hernia is less common than the axial sliding hernia. This type of diaphragmatic hernia also entails part of the stomach passing through the diaphragm into the chest cavity. However, the part of the stomach that has passed through forms a type of sack, which lies on the diaphragm next to the esophagus. The esophagus leads directly into the part of the stomach that is not bulging through the diaphragm (“paraesophageal” means “next to the esophagus”).

Hybrid forms

All other forms of hiatus hernia are referred to as so-called “hybrid forms”. Thus, in rare cases the entire stomach may pass through the diaphragm and lie in the abdominal cavity.

What are the symptoms of a diaphragmatic hernia?

Around 60 per cent of patients who present a hiatus hernia do not experience any symptoms. The majority of cases are axial hiatus hernias in which only a small part of the stomach has entered the diaphragm. If symptoms are present, they are usually the classic symptoms of gastroesophageal reflux disease, which is colloquially referred to as heartburn. The reason for this is that when the stomach passes through the diaphragm, it also results an increased amount of gastric acid reaching the esophagus. Normally, the transgression of gastric acid is prevented by the narrow passage in the diaphragm opening. It results in pain behind the breastbone, difficulty in swallowing and even to anemia in some cases. Pain behind the breastbone usually gets worse in the lying position.

The rarer paraesophageal hernia may also give rise to a sensation of pressure in the chest and to heart complaints if the heart’s ability to beat becomes impaired by the contents of the hernial sac.

How does the doctor diagnose a diaphragmatic hernia?

A detailed anamnesis gives the first indications of a hiatus hernia. If the patient describes typical symptoms such as heartburn, pain behind the breastbone and difficulty swallowing, the doctor should consider a potential diaphragmatic hernia. Given that two thirds of diaphragmatic hernias do not cause any symptoms, they are often discovered by chance. The doctor will perform a (gastroscopy) in order to confirm the presence of a hiatus hernia. This enables the physician to track the esophagus and to illustrate the position and spread of the diaphragmatic hernia.

Alternatively, examinations using radiographic contrast agents can be carried out. This involves the patient swallowing a liquid, which is visible on the X-ray image. It is then possible to trace the location and position of the stomach on the X-ray image.

How is a diaphragmatic hernia treated?

If the diaphragmatic hernia does not trigger any symptoms then it does not have to be treated. Especially more minor forms of a diaphragmatic hernia often occur without symptoms and should not be a cause for concern.

When symptoms emerge such as heartburn, pain and difficulty swallowing, the first step should be to treat the complaint in a non-invasive manner. In other words, instead of surgery other treatment options for heartburn should be exhausted at first. An important step is to adjust your diet. Alcohol in particular increases the amount of gastric acid that is produced and can reach the esophagus. Cigarette consumption should also be limited. Spicy and heavily seasoned food may also give rise to a worsening of symptoms.

Given that excess weight represents a risk factor for the emergence and exacerbation of a diaphragmatic hernia, the patient should aim to lose weight.

What do you do if the diaphragmatic hernia treatment is unsuccessful?

If these measures do not alleviate symptoms, a diaphragmatic hernia can also be treated with an operation. The most common operation method is the fundoplication. This involves the stomach position being changed such that it is once again possible to close the passage from the esophagus to the stomach. This prevents food residues and gastric acid from regurgitating back into the esophagus and causing problems there. Yet in most cases, it is possible to improve symptoms without an operation and therefore making it unnecessary to perform a fundoplication.


A diaphragmatic hernia is a common disease that is often mild and does not present any symptoms. However, if symptoms such as pain occur, patients can be treated by adjusting their eating habits or by operating on the hiatus hernia.

Andre Sommer, MD

Andre Sommer, MD

I’m André, a medical doctor from Berlin. Together with a team of medical doctors, nutritionists and data scientists we empower people to understand digestive issues with our app Cara.