Reflux and Hiatal Hernia: Symptoms, Diagnosis and Treatment

A burning sensation behind the breastbone, a bitter or sour taste rising into the mouth, and symptoms that worsen on lying down are among the most common digestive complaints. Many people call this heartburn and manage it with medication for years. This article explains what reflux is, how it relates to hiatal hernia, why particular tests are performed and at what point surgery becomes relevant.

What Is Reflux?

Between the oesophagus and the stomach lies a zone that contracts and relaxes, acting as a one way valve (the lower oesophageal sphincter). When this zone relaxes too often or for too long, stomach contents flow back into the oesophagus. The stomach is built to withstand its own acid; the lining of the oesophagus is not. That difference is the source of the symptoms.

Occasional backflow occurs in everyone. When symptoms recur more than twice a week, impair quality of life or cause damage to the oesophagus, the condition is called gastro oesophageal reflux disease.

What Is a Hiatal Hernia?

The oesophagus passes from the chest into the abdomen through an opening in the diaphragm called the hiatus. When this opening widens, the upper part of the stomach slides upward into the chest. This is a hiatal hernia.

A hernia promotes reflux in two ways: the pinching support provided by the diaphragmatic crura is lost, and the natural angle between the stomach and the oesophagus is distorted. For this reason reflux tends to be more frequent and more persistent in people with a hiatal hernia.

Hernias are classified by type. The most common is the type 1 sliding hernia, where reflux usually dominates the picture. Paraoesophageal hernias, in which the stomach moves up alongside the oesophagus, are less common; because they carry a risk of incarceration, the approach to them may differ.

What Are the Symptoms?

Typical symptoms:

• Heartburn: usually after meals, worse on bending forward or lying down.
• Sour or bitter fluid rising into the mouth: particularly at night when lying flat.
• Pain or pressure behind the breastbone.
• Bloating, early fullness, belching.

There are also less familiar symptoms that often lead patients to other specialties: chronic cough, hoarseness, a sensation of a lump in the throat, frequent throat clearing, dental enamel erosion and breathlessness at night. It is not unusual for a patient to be followed for a long time in ear, nose and throat or respiratory clinics before reflux is identified as the cause.

Warning symptoms are a separate matter and should be assessed without delay: difficulty swallowing, pain on swallowing, unintentional weight loss, anaemia, blood in vomit and black stools. It should also be remembered that chest pain can originate from the heart; new onset chest pain is assessed from a cardiac perspective before being attributed to reflux.

How Is It Diagnosed?

Diagnosis does not rest on symptoms alone; objective data are required, particularly when surgery is being considered.

• Endoscopy (gastroscopy): the lining of the oesophagus is inspected directly. The degree of inflammation, the presence and size of a hernia and any separate problem on the stomach side are assessed. Biopsies are taken where needed.
• 24 hour pH monitoring: shows whether acid genuinely refluxes into the oesophagus and whether the episodes correspond to the symptoms. It is decisive in patients considered for surgery whose endoscopy is normal.
• Oesophageal manometry: measures the contractile strength of the oesophagus. If a full wrap is performed in a patient with severely weak contractions, difficulty swallowing may become persistent; the type of operation is therefore chosen according to this measurement.
• Barium swallow: particularly in large hernias, it shows the anatomy and how much of the stomach has moved into the chest.

Medication and Its Limits

The first step is lifestyle modification together with medication that reduces stomach acid (proton pump inhibitors). These drugs reduce acid and therefore relieve burning to a large extent. However, they do not stop the reflux itself. The mechanical problem, that is the loosened valve or the hernia, remains.

This distinction explains the logic behind the decision to operate. Because backflow continues even when acid is suppressed, regurgitation, cough and hoarseness do not resolve with medication in some patients. On the lifestyle side, the measures with demonstrated effect are: losing excess weight, stopping smoking, leaving at least three hours between the last meal and lying down, raising the head of the bed, and reducing foods identified as triggers for that individual.

When Is Surgery Considered?

Surgery is not considered for everyone with reflux, but for specific situations:

• Symptoms persisting despite medication at an adequate dose and duration.
• Symptoms returning immediately when medication is stopped, in a patient who does not wish to take medication for life.
• Predominant symptoms that do not respond to acid suppression, such as regurgitation, cough or hoarseness.
• A large or paraoesophageal hernia.
• Complications such as a stricture of the oesophagus or Barrett's oesophagus.

The decision is not made on any one of these headings alone, but by evaluating endoscopy together with pH monitoring and manometry where indicated.

How Is the Operation Performed?

The operation is performed by the closed method, that is laparoscopically. It has two core steps:

1. Hernia repair. The portion of stomach that has moved into the chest is returned to the abdomen and the widened opening in the diaphragm is narrowed with sutures.

2. Fundoplication. The upper part of the stomach is wrapped around the lower end of the oesophagus to create a new valve. A full wrap is called a Nissen and a partial wrap a Toupet. A partial wrap may be preferred in patients whose oesophageal contractions are weak.

Whether another procedure should be performed in the same session is also assessed. In patients with severe obesity who also have reflux, gastric bypass is a separately evaluated option addressing both weight and reflux; in this group sleeve gastrectomy can worsen reflux, which makes the choice of method a topic in its own right.

What to Expect After Surgery?

The hospital stay is usually short. Feeding begins with liquids and soft foods and returns to normal within a few weeks.

• Difficulty swallowing: common in the first weeks, caused by swelling and usually temporary. This is why the diet is advanced in stages.
• Gas accumulation and inability to belch: may occur because of the new valve. It decreases over time.
• Bloating: may occur early on and is managed with small, frequent meals.

In the long term, the need for acid medication disappears or decreases markedly in a substantial proportion of patients. That said, the hernia can recur over the years; the likelihood varies with the size of the hernia and individual factors. Weight control and avoiding strain that raises intra abdominal pressure matter in this respect.

Conditions That Are Often Confused

Burning in the chest is not always reflux. Cardiac pain, symptoms caused by gallstones, gastric ulcer and motility disorders of the oesophagus can all present similarly. For that reason, prolonged or new onset symptoms should be assessed rather than self diagnosed.

Disclaimer. This article is provided for general information only. It does not constitute medical advice, diagnosis or a treatment recommendation, and it is not a substitute for examination, diagnosis and treatment by a physician. The content is not tailored to any individual and is not intended as advertising. Do not start, change or stop any treatment on the basis of the information here. Consult your own doctor about any decision concerning your health and see a healthcare provider about your symptoms. The site owner accepts no liability for any consequences arising from use of this content. Last updated: 2026-09-01.