Hiatal Hernia: What You Need to Know

Normally, your esophagus passes through the hiatus – a small opening in the diaphragm that allows the esophagus to pass from the chest into the abdomen. A hiatal hernia happens when the upper part of your stomach bulges through that opening.

While this sounds alarming, hiatal hernias are actually quite common – and it’s especially prevalent in people with obesity due to the increased pressure on the abdomen. (Other contributing factors include pregnancy and inherited anatomical differences.) In fact, up to 90% of individuals with obesity may have a hiatal hernia without even knowing it. 

Symptoms (or Lack Thereof)

One surprising thing about hiatal hernias is that some people don’t feel a thing. These are called asymptomatic hernias. Hiatal hernias are graded from I to IV based on symptoms and how much of the stomach has moved above the diaphragm. Grade I (sliding hernia) is the most common, with Grade IV being the most severe and likely to have associated symptoms. However, there have been case reports of even a IV presenting with no symptoms, with doctors finding it incidentally.¹

When symptoms do appear, they can be uncomfortable and disruptive. Issues usually stem from the way the hernia disrupts the normal function of the lower esophageal sphincter (a muscular valve that keeps stomach acid where it belongs).

 Common signs include:

• A burning sensation in the chest
• Chest pain
• Regurgitation of food or stomach acid
• Difficulty swallowing

Other symptoms might not be as obvious. Some people experience a chronic cough, hoarseness, or a sore throat, especially in the mornings – signs that acid may be reaching the upper airway. Others feel bloated or too full after meals, or notice worsening symptoms when lying down or bending over.

In more severe cases, a large hernia can trap part of the stomach in the chest cavity, leading to pain, nausea, or even trouble breathing. This is known as a paraesophageal hernia, and it may require more urgent attention. This type of hernia is less common but can be more serious and cause complications if not treated.

Why Does it Matter?

The relationship between hiatal hernia, GERD (gastroesophageal reflux disease), and bariatric surgery can get confusing – even for clinicians – because these conditions often overlap, and their order of appearance isn’t always straightforward. Not all patients follow the same path, but here’s how these conditions often relate:

• Hiatal hernia can cause GERD. When part of the stomach pushes through the diaphragm, it can disrupt the lower esophageal sphincter (LES), allowing acid to flow back into the esophagus, leading to GERD symptoms like heartburn, chest discomfort, or regurgitation.
• Obesity increases the risk of both GERD and hiatal hernia. The pressure from excess abdominal weight makes it more likely that a hernia will form and, independently, that reflux will occur, whether or not a hernia is present. This explains why GERD and hiatal hernia frequently appear together in people with obesity.
• Some patients already have GERD before surgery. In these cases, an undiagnosed or untreated hiatal hernia could be the hidden cause.

Certain types of bariatric surgery, like gastric bypass, can improve GERD by rerouting acid away from the esophagus. But some surgeries can also worsen GERD, especially if a hiatal hernia is left unrepaired. Either situation depends on the procedure and anatomy of the patient.

Sometimes, a hiatal hernia isn’t diagnosed until right before or even during bariatric surgery. Preoperative imaging or upper endoscopy may reveal one, but sometimes, it’s the surgical view itself that confirms the presence of a hernia.

Many bariatric surgeons choose to repair the hernia at the same time as the weight-loss surgery. This combined approach can reduce the risk of GERD, improve post-op comfort, and eliminate the need for a second surgery later. Situations where this might not be possible include when the patient’s anatomy makes the repair technically difficult or risky, or when performing it would significantly extend the surgery time for a high-risk patient. Even if the hernia is asymptomatic, a surgeon may elect to repair even small ones proactively.

A symptomatic hiatal hernia that isn’t corrected may continue to cause acid reflux, chest discomfort, or difficulty swallowing after surgery. Even an asymptomatic hernia could become problematic later, especially after sleeve gastrectomy, which can increase internal pressure on the stomach. In both cases, the ongoing presence of a hernia can interfere with healing, sleep, comfort, and nutritional intake – factors that play a role in a patient’s ability to recover and maintain weight loss.

Treatment Options

Hiatal hernias can be managed and even fixed. For small, symptom-free hernias, lifestyle changes may be enough to reduce abdominal pressure and minimize acid reflux:

• Avoid large or heavy meals, especially before lying down.
• Steer clear of acidic, spicy, or fried foods that can trigger heartburn.
• Elevate the head while sleeping to prevent nighttime reflux.

For larger hernias or those causing significant gastric issues, surgical intervention may be the best option and, as mentioned before, can often be done at the same time as weight-loss surgery. The most common technique is laparoscopic repair, a minimally invasive procedure using small incisions and a camera to guide the process.

Total Care

Hiatal hernias are more common than you might think, so screening for and repairing them is an important part of comprehensive bariatric care. While many hernias cause no symptoms, those that do can interfere with digestion, comfort, and surgical recovery.

While reflux improves in many patients after surgery, it can also worsen in about 20% of cases after a gastric sleeve. To reduce this risk, our team now repairs hiatal hernias during sleeve gastrectomy when one is found. Since up to 70% of individuals with obesity have a hiatal hernia – and these hernias are known to contribute to reflux – addressing both at once may significantly lower the chances of developing reflux after surgery.

If you’re considering weight-loss surgery and struggling with acid reflux or unexplained upper GI-related discomfort, ask us about a hiatal hernia evaluation. Treating it early can make a big difference in your comfort and your results.

¹Qirem, M., Yaghi, S., Okwesili, B., Atiyat, R., & Bains, Y. (2024). Incidental Discovery of Asymptomatic Stage IV Hiatal Hernia With Complete Gastric Thoracic Herniation: A Case Report. Cureus, 16(4). https://doi.org/10.7759/cureus.58560