Hiatal hernias are fairly common, and many don't present serious problems. However, when the affected part of your stomach gets stuck inside your chest cavity and its blood supply gets cut off or reduced, the hernia becomes a surgical emergency, according to the Medical College of Wisconsin (MCW).
How Hiatal Hernias Happen
The hiatus is the normal connection between your stomach and your esophagus, and is located within the muscle known as your diaphragm, says Harvard Health Publishing. When the hiatus become weak, part of your stomach may slip out of your abdomen and into your chest cavity, explains Harvard Health. This condition is called a hiatal hernia.
There are two main types of hiatal hernia. The sliding type is most common, says MCW. When this happens, just the top of your stomach slides up above the diaphragm.
The other type is called a paraesophageal hiatal hernia. In this type, the upper part of your stomach — called the fundus — goes into your chest, explains NewYork-Presbyterian/Columbia University Medical Center's Department of Surgery. When this occurs, it's possible for this stomach section to become stuck and strangulated, or cut off.
"About 95 percent of hiatal hernias are the sliding type," explains Abdul Haseeb, MD, an assistant professor of gastroenterology at the Stritch School of Medicine in Chicago. "They are not dangerous. Only about five percent of hiatal hernias are paraesophageal, with the fundus of the stomach pushing through into the chest. And only about five percent of these hernias become trapped."
However, he says, "if the trapped part loses its blood supply, it's a surgical emergency because stomach tissue will start to die and the hernia may rupture, which is a life-threatening event."
Read more: Exercising With a Hernia
Symptoms of a Strangulated Hiatal Hernia
When hiatal hernias cause symptoms, they're typically from gastric juices seeping up into the esophagus from the stomach, causing heartburn, reports the Medical College of Wisconsin. Though paraesophageal hernias don't always provoke symptoms, when they do, in addition to heartburn, you may have:
- Chest pain that gets worse after eating
- Upper belly pain
- Shortness of breath, if the stomach takes up lung space
- Difficulty swallowing
These symptoms will worsen if the hernia becomes strangulated. "Symptoms of strangulation include severe chest pain and complete inability to swallow," says Dr. Haseeb.
A report on strangulated hiatal hernias, published in March 2017 in the journal Clinics in Surgery, states that it can cause internal bleeding, death of the strangulated part of the stomach and perforation of the hernia with spilling of blood and stomach contents into the chest. This condition can be fatal unless surgery is performed very quickly.
If you ever experience a sudden onset of severe chest pain and the complete inability to swallow, call 911.
Read more: Exercise and Inguinal Hernias
Who Is at Risk of Strangulated Hiatal Hernia?
Strangulated hiatal hernia is very rare. It only occurs in paraesophageal hernias, which are also rare. According to the Clinics in Surgery report, risk factors for paraesophageal hernia are old age, smoking, diabetes and diseases that weaken connective tissue, called collagen vascular diseases.
People who have paraesophageal hiatal hernia and have symptoms may elect to have surgery to fix the hernia. This will prevent strangulation. During this surgery, the stomach will be placed back inside the abdomen, explains MedStar Washington Hospital Center. The hiatus will be tightened and the valve between the esophagus and the stomach, called the esophageal sphincter, will also be tightened.
If you haven't taken this preemptive step and your paraesophageal hiatal hernia becomes strangulated, the surgery is more complicated. "A person with a strangulated hernia is rushed to the operating room," says Dr. Haseeb. "The stomach and chest are opened. Part of the stomach usually needs to be removed. After surgery, antibiotics are given to treat infection."
Avoiding a Strangulated Hiatal Hernia
If you have hiatal hernia symptoms that include heartburn, pain or trouble swallowing, tell your doctor. If these symptoms do not respond to simple treatments and lifestyle changes to reduce heartburn, your doctor may recommend an imaging study, such as an endoscopy, to confirm a hiatal hernia and identify the type, says Columbia's surgery department.
If you're diagnosed with a paraesophageal hiatal hernia and you have significant symptoms, discuss repairing your hernia, advises Harvard Health. Strangulated hernia is very rare, but very serious.
Is This an Emergency?
- Abdul Haseeb, MD, MPH, assistant professor of medicine, division of gastroenterology, Stritch School of Medicine, Chicago
- Clinics in Surgery: “Incarcerated Paraesophageal Hiatal Hernia”
- Medical College of Wisconsin: “Paraesophageal Hernia (Hiatal Hernia)”
- Harvard Health Publishing: "Hiatal Hernia"
- NewYork-Presbyterian/Columbia University Medical Center's Department of Surgery: "Esophageal Disorders Program - Hiatal Hernia"
- MedStar Washington Hospital Center: "Hiatal and Paraesophageal Hernia Repair"