When is Hiatal Hernia Life-Threatening?

For most people, a small hiatal hernia, also known as a stomach hernia, will not cause symptoms. With larger hernias, however, symptoms may include heartburn, belching, a weird taste in your mouth, or regurgitation. Typically, these are not serious, but in some cases, they can cause potentially life-threatening complications.

This article explains symptoms of a large hiatal hernia as well as rare complications and when to seek medical care.

Unusual or Worsening Hiatal Hernia Symptoms

Typically, a small hiatal hernia may not cause any symptoms. However, a larger hiatal hernia can change the structures and mechanisms that keep food and acids where they belong.

This can lead to symptoms such as:

• Heartburn
• Regurgitation
• Belching or hiccupping shortly after eating
• A stinging sensation in the throat
• Difficulty swallowing
• A sour or bitter taste in the mouth
• Bad breath

When a hiatal hernia occurs, it can change the position of a muscular valve called the lower esophageal sphincter (LES). This allows the contents of the stomach to back-flow into the esophagus (known as reflux), which can lead to symptoms.

Generally speaking, problems only occur when a hernia becomes enlarged. If the LES weakens, which can happen with age or during pregnancy, symptoms will get progressively worse.

Symptoms can be worsened by eating foods that trigger gastroesophageal reflux (GERD), eating large meals, lying down after eating, and stress.

If you have a hiatal hernia, avoid food that is fatty, oily, highly acidic, or processed. Also avoid citrus fruits such as oranges or limes, which can cause irritation.

Complications from Hiatal Hernia Symptoms

Broadly speaking, there are two types of hiatal hernia: a sliding hiatal hernia and a paraesophageal hernia. While a sliding hernia is the most common, accounting for around 95% of all diagnoses, a paraesophageal hernia is potentially more serious and related to complications.

To understand the problems that could potentially develop with a hernia, it helps to have an idea of what a hernia is:

• With a sliding hiatal hernia, the junction of the esophagus and stomach (referred to as the gastroesophageal junction) will protrude through a hole in the diaphragm, called the hiatus. This is the space through which the esophagus passes. It is called "sliding” because the herniated part of the stomach can slide in and out of the chest cavity as you swallow.
• With a paraesophageal hernia, the stomach bulges into the chest. While many paraesophageal hernias are a progression of a sliding hernia, others can occur suddenly if there is a structural weakness in the diaphragm.

Unlike a sliding hernia, a paraesophageal hernia doesn't readily slide in and out of the hiatus. Rather, it can get progressively larger and slip even further into the chest cavity as time goes by. It is at this later stage that the complications can become serious and, in rare cases, life-threatening.

Complications may include:

• Esophageal compression
• Gastric obstruction
• Strangulation
• Intrathoracic stomach, when the stomach slips entirely into the chest cavity

Esophageal Compression

Compression of the esophagus can occur as the hernia presses against the esophageal wall. When this happens, food can get stuck in the esophagus, causing chest pain after eating and difficulty swallowing (dysphagia).

While esophageal compression is not considered a medical emergency, it may require medications to or even surgery to alleviate or prevent worsening symptoms.

Incarcerated Hiatal Hernia

Incarceration occurs when the herniated portion of the stomach becomes trapped in the hiatus. In some cases, the symptoms of incarceration may be long-term but minimal (mostly a sensation of chest pressure as food passes through the upper digestive tract). But, it can cause obstruction or impede blood circulation.

Incarceration itself is not a medical emergency unless there's a severe obstruction or if it results in ischemia (affects blood flow to that part of the stomach).

Volvulus

Volvulus is when a herniated stomach twists more than 180 degrees, causing a severe gastric obstruction. While it can occur with hiatal hernia, it can also occur without it and is very uncommon.

Symptoms may include:

• Difficulty swallowing
• Chest pain after eating
• Belching
• Vomiting

If this problem progresses, it can cause upper abdominal pain and distention, vomiting leading to nonproductive retching, and gastric bleeding (due to the abnormally increased blood pressure).

Acute symptomatic volvulus generally occurs in people over age 50 and is considered a medical emergency with a 30% to 50% risk of mortality.

Strangulation

Strangulation is a cut-off of the blood supply to the stomach, either due to volvulus or incarceration. Symptoms include:

• A sudden, sharp chest pain
• Fever
• Fatigue
• Bloating
• Vomiting
• An inability to pass gas
• Constipation
• Warmth or redness over the herniation
• Rapid heart rate
• Bloody or tarry stools (due to gastrointestinal bleeding)

Intrathoracic Stomach

An intrathoracic stomach is a rare condition in which the stomach slips entirely into the chest cavity. Not all cases cause symptoms, but the most common signs are dyspnea (shortness of breath) and a feeling of chest fullness and pressure.

Other symptoms can include:

• Vomiting
• Retching
• Difficulty swallowing
• Gastrointestinal bleeding
• Aspiration pneumonia, which is caused when food is coughed up into the lungs

The enlarged hiatal gap can cause other organs to slip into the chest cavity, including the pancreas, liver, or colon. Surgery is the only means to correct this rare but serious complication.

Hiatal Hernia Pain: When to Worry

Hiatal hernias generally do not need to be medically managed unless the symptoms are getting worse or are persistent. You should see your healthcare provider if your hiatal hernia symptoms don't improve despite conservative management.

The vast majority of hiatal hernia symptoms can be easily managed with over-the-counter medications, weight loss, and an adjustment to your diet. In some cases, you may need to adjust your prescription drugs.

Hiatal Hernia Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

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Summary

A hiatal or stomach hernia is a common problem, especially for adults over 50. Common symptoms include heartburn, reflux, chest pain, irritation in the throat, belching, and regurgitation. 

If a hernia becomes enlarged and slips into the chest cavity, you may experience serious health complications that require immediate medical attention. If you have a high fever, severe chest pain, a rapid heart rate, bloody stool, or dry heaves, go to an emergency room for treatment.