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Hiatal Hernia

A hiatal hernia occurs when part of the stomach pushes up through the diaphragm into the chest cavity, which can weaken the barrier against acid reflux. It becomes more common with age and usually causes no symptoms12; weight loss, meal timing and a raised head of the bed help when it causes reflux, and acid-suppressing medicine treats the reflux rather than the hernia.

Gut & Digestive Evidence-Based

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Definition

What Is Hiatal Hernia?

A hiatal hernia occurs when the upper portion of the stomach herniates (pushes upward) through the hiatus, the opening in the diaphragm through which the esophagus normally passes. This disrupts the anatomical barrier between the stomach and esophagus, allowing acid and stomach contents to reflux freely.

The lower esophageal sphincter (LES), the muscular valve that normally prevents acid from flowing back into the esophagus, relies partially on the diaphragm for mechanical support. When the stomach herniates above the diaphragm, this support is lost, and even a competent LES may fail to prevent reflux.

An estimated 55 to 60% of people over 50 have a hiatal hernia, and only a small minority develop symptoms12.

โš ๏ธ Long-term acid suppression with PPIs3 (the standard treatment for GERD, the reflux a hiatal hernia can cause) is associated with reduced absorption of vitamin B12, magnesium, iron and calcium and with more gut infections such as C. difficile; links to kidney disease come mainly from observational studies of very low certainty.
Two drawings of the esophagus passing through the diaphragm into the stomach: a normal one with the whole stomach below the diaphragm, and a hiatal hernia with the top of the stomach pushed up through it

Types of Hiatal Hernia

Type I, Sliding Hiatal Hernia (Over 90%)

The gastroesophageal junction and a portion of the stomach slide in and out of the chest through the hiatus. The hernia appears and disappears with position changes and intra-abdominal pressure. This is the most common type, and it can cause GERD, heartburn, regurgitation and chest discomfort. Responds well to dietary and positional interventions.

Type II to IV, Paraesophageal / Rolling (Under 10%)

The gastroesophageal junction remains in position, but part of the stomach rolls up beside the esophagus. Less likely to cause acid reflux but more dangerous: the herniated stomach portion can become trapped, twisted (volvulus) or strangulated. May require surgical repair. Symptoms: chest pain, difficulty swallowing, early satiety, vomiting.

By the Numbers

Hiatal Hernia by the Numbers

10% or fewer
of people with a hiatal hernia develop symptoms12
55 to 60%
of adults over 50 have a hiatal hernia, though few have symptoms12
About 1.4ร—
the odds of a hiatal hernia in men compared with women, in a meta-analysis of endoscopy studies11
Over 90%
of hiatal hernias are the sliding type, the kind closely linked with reflux10
About 2ร—
the odds of a hiatal hernia over age 50, and again with a BMI above 25, in a meta-analysis of endoscopy studies11
50 to 94%
of people with GERD have a sliding hiatal hernia, in study results12
Signs & Symptoms

Symptoms of Hiatal Hernia

Symptoms mainly come from reflux and a weakened lower esophageal sphincter.

SymptomWhat happens
GERD & Esophageal Symptoms
Heartburn (Pyrosis)Burning in the chest or throat as acid refluxes into the esophagus, which lacks the stomach's protective mucus lining. Worsens after meals, when lying down, bending forward or with increased abdominal pressure (coughing, straining). The most common symptom12.
Acid RegurgitationSour or bitter fluid, gastric acid mixed with partly digested food, rising into the mouth or throat. Often worsens at night when lying flat, causing "wet burps," bad breath and tooth enamel damage typical of chronic GERD.
Dysphagia (Difficulty Swallowing)Food getting stuck in the throat or chest, caused by esophageal inflammation (esophagitis), strictures from chronic acid damage or mechanical obstruction from the herniated tissue. See a doctor promptly, particularly with weight loss. Call 911 or go to the emergency department if you suddenly cannot swallow, or food sticks and will not pass.
Chronic Cough & LaryngitisAcid microaspirations trigger airway irritation, causing a persistent dry cough (worse at night or in the morning), hoarseness, sore throat and frequent throat clearing. Sometimes attributed to allergies, asthma or postnasal drip when laryngopharyngeal reflux (LPR) is contributing.
Upper GI & Systemic Symptoms
Belching, Bloating & GasExcessive belching from swallowed air or fermentation; upper abdominal bloating from impaired gastric emptying. The herniated stomach segment may trap gas, causing persistent upper abdominal fullness or pressure.
Chest Pain (Non-Cardiac)Acid-triggered esophageal spasm causes chest pain that is indistinguishable from cardiac pain, a common ER presentation. The pain may radiate to the jaw, arms or back. Always rule out cardiac causes first. Once confirmed non-cardiac, it is usually managed as reflux, with diet and lifestyle measures alongside medical treatment.
Nausea & VomitingImpaired gastric emptying from positional dysfunction of the stomach and vagal nerve irritation causes nausea, particularly in the morning or after large meals. In large paraesophageal hernias1, vomiting can be severe and indicate a mechanical obstruction requiring urgent surgical attention. Sudden chest pressure or severe upper abdominal pain, retching without bringing anything up, new difficulty swallowing, or being unable to belch or vomit can mean a trapped or twisted stomach, or a heart problem: go to emergency care at once9.
Iron-Deficiency AnemiaChronic irritation and micro-bleeding from the herniated gastric mucosa (Cameron erosions) cause slow, occult blood loss, leading to iron-deficiency anemia. Unexplained iron deficiency, especially in men and in women past menopause, needs prompt tests of the upper and lower gut, usually endoscopy and colonoscopy, because stomach and colorectal cancers can show up this way; a hiatal hernia may be one cause21.
Causes

Causes of Hiatal Hernia

A hiatal hernia forms when pressure inside the abdomen pushes the stomach up through the opening in the diaphragm; age, weight and some past surgery make that more likely10.

CauseHow It Contributes to Hiatal HerniaWhat Helps
Raised pressure in the abdomen from excess weightBeing overweight is a key risk factor10; a BMI above 25 roughly doubled the odds in a meta-analysis11, and abdominal fat in particular was linked with hiatal hernia in a genetic study13.Weight management and smaller meals (Treatment Comparison)
AgeThe tissue around the opening in the diaphragm weakens with age; hiatal hernia was about twice as likely after 50 11.The reflux measures in Treatment Comparison; acid-suppressing medicine when symptoms need it (conventional care)
Heavy physical workHeavy physical labor was an independent risk factor in an endoscopy study of 685 people13.Smaller meals, which lower stomach volume and the pressure inside the abdomen (Treatment Comparison)
Previous surgery on the esophagus or stomachPast esophageal surgery and partial or full removal of the stomach are known risk factors10.Assessment by a surgical team, with decisions shared with you (conventional care)
Diagnosis

How Hiatal Hernia Is Diagnosed

TestWhat it shows
Primary Diagnostic Tests
Upper Endoscopy (EGD)The most definitive diagnostic tool: directly visualizes the hernia, assesses esophageal damage (esophagitis, Barrett's esophagus6, a precancerous change), identifies Cameron erosions and rules out malignancy. Performed under light sedation. Recommended for people with alarm symptoms (dysphagia, weight loss or anemia), symptoms that do not respond to treatment or long-standing reflux with other risk factors.
Barium Swallow X-RayPatient swallows barium contrast while fluoroscopic X-rays capture real-time movement through the esophagus and stomach. Excellent for showing the hernia anatomy and the degree of herniation; also used to evaluate paraesophageal hernias. Also detects esophageal motility disorders.
Esophageal pH MonitoringA pH probe worn for 24 to 48 hours measures acid exposure time in the esophagus. Quantifies the frequency and duration of reflux episodes and correlates them with symptoms. A wireless pH capsule attaches to the esophageal wall for 48-⁠hour wireless monitoring without a nasal catheter.
Functional & Nutritional Assessment
SIBO Breath TestLong-term acid suppression may make small bowel bacterial overgrowth more likely, but how often it occurs is unclear. A breath test can be considered when bloating and gas are prominent.
Nutritional Deficiency PanelLong-term acid suppression is associated with reduced absorption of B12, magnesium, iron and calcium3. Testing is reasonable when symptoms or other risk factors suggest a deficiency; routine screening of everyone on a PPI is not recommended.
Esophageal ManometryMeasures the strength and coordination of esophageal muscle contractions and LES pressure. Identifies if low LES resting pressure, esophageal dysmotility or achalasia is contributing to reflux symptoms. Required before anti-reflux surgery to ensure normal esophageal peristalsis.
Treatment Comparison

Conventional and Holistic Treatment for Hiatal Hernia

๐ŸŒฟ HOLISTIC
๐Ÿ’Š CONVENTIONAL
๐ŸŒฟ

Holistic / Functional Approach

Dietary triggers, meal timing, positional strategies, DGL licorice, aloe vera, digestive enzymes

Primary Strategy
Reduce intra-abdominal pressure, reduce how much reflux reaches the esophagus and treat SIBO where it is actually demonstrated
Key Supplements
DGL licorice, slippery elm, aloe vera, zinc carnosine, digestive enzymes
Timeline
Weight loss, raising the head of the bed and avoiding late meals have the best evidence; how quickly symptoms improve varies from person to person.2
Advantage
Focuses on lifestyle measures with the best evidence for reflux (weight loss, head-of-bed elevation, no late meals), alongside medical treatment where needed

Full Holistic Approach Includes

  • Eat smaller meals (4 to 5 small vs. 2 to 3 large): this reduces stomach volume and intra-abdominal pressure, so less acid is pushed up into the esophagus
  • Nothing to eat 3+ hours before bed: this gives the stomach time to empty before lying down; prevents nocturnal acid exposure
  • Head-of-bed elevation (6 to 8 inches, 15 to 20 cm) using a wedge pillow: gravity reduces acid contact time with esophageal mucosa during sleep. This is one of the better-supported lifestyle measures for nighttime reflux, though the size of the reduction varies between studies.2
  • DGL licorice (chewable tablets before meals), proposed to stimulate protective mucus, without raising blood pressure
  • Slippery elm bark powder: thought to form a protective mucilage layer over the inflamed esophagus and stomach lining
  • Aloe vera juice from the inner leaf fillet, 2 to 4 oz (60 to 120 mL) before meals, tested for reflux symptoms only in a small pilot trial18
  • Zinc carnosine, studied mainly in stomach ulcers rather than reflux
  • Digestive enzymes with meals: proposed to support complete digestion and so reduce fermentation and gas pressure that pushes against the LES
  • Weight management: weight loss has the strongest evidence of any lifestyle measure for reflux symptoms
  • Address SIBO if a test shows it
โœ… Key insight: Reflux is usually a problem of acid reaching the wrong place rather than of too much acid, which is why barrier and lifestyle measures help. Low stomach acid is not a reliable explanation for reflux, and a betaine HCl "challenge" is not a validated test. Self-massage, heel-drop and visceral manipulation routines have no controlled trial evidence and cannot move the hernia back through the diaphragm; the parts worth keeping are diaphragmatic breathing, upright posture and a pause around meals4.
Supplement Protocol

Evidence-Based Supplements for Hiatal Hernia

Evidence for these supplements in reflux is limited and mostly from small studies; none treats the hernia, and none replaces prescribed treatment.

SupplementWhat it is forTypical rangeTimingNotes & cautions
DGL Licorice (Deglycyrrhizinated)Proposed to stimulate mucus production in the esophageal and gastric lining; trial evidence is limited. Also proposed to reduce H. pylori adhesion to the gastric mucosa and to have mild anti-inflammatory effects on esophageal tissue. DGL form does not raise blood pressure.400 to 800 mg chewable tablets, 2 to 3x/day20 minutes before meals and at bedtime, must be chewed for saliva to activate the mucosa-stimulating effectChewable form is essential; swallowed capsules do not stimulate esophageal mucosa. DGL is the safe form (glycyrrhizin removed). Whole licorice root raises BP; avoid for GERD use.
Slippery Elm BarkForms a thick, gel-like mucilage that coats and soothes the esophagus, stomach and intestinal lining. The coating is thought to shield the inflamed lining from acid, which may ease symptoms. A traditional remedy; clinical trial evidence is limited.1 to 2 tsp powder mixed in warm water, 3x/dayBetween meals and before bedPowder form mixed in water creates the most effective mucilage. Capsule form is less effective. Generally well tolerated.
Aloe Vera Juice (Inner Leaf)Contains acemannan and other compounds proposed to reduce inflammation in the esophagus and stomach. A small 2015 pilot randomized trial in 79 adults found aloe vera syrup reduced the frequency of reflux symptoms over 4 weeks and was well tolerated18.2 to 4 oz (60 to 120 mL) before meals (inner leaf fillet juice only)15 to 20 minutes before mealsInner leaf fillet only; whole leaf contains aloin, a potent laxative. Choose decolorized, purified aloe vera juice. Avoid it in pregnancy and while breastfeeding, stop it and see a doctor if you feel unwell, since aloe leaf extracts have been linked to cases of acute hepatitis, and check with your clinician if you take medicine for diabetes, since it may lower blood sugar19.
Zinc CarnosineA chelated compound of zinc and L-carnosine that is uniquely stable in the stomach, releasing slowly over 2+ hours in direct contact with the gastric mucosa. Studied for protecting the stomach lining, mainly in gastric ulcers.75 mg 2x/day30 minutes before mealsStudied mainly in Japanese trials for gastric ulcers. H. pylori infection needs antibiotic treatment; zinc carnosine is not a substitute. Take it at least 2 hours apart from antibiotics, since zinc and some antibiotics reduce each other's absorption17.
Digestive Enzymes (with meals)Incomplete protein and fat digestion leads to fermentation, excess gas production and increased intra-abdominal pressure, all of which worsen LES pressure and hernia symptoms. Enzyme blends (protease, lipase, amylase) are proposed to reduce this; that is a proposed mechanism, not a tested benefit in reflux.1 to 2 capsules per mealAt the beginning of each mealAvoid formulas with betaine HCl, which irritates an inflamed esophagus; low stomach acid is not a reliable explanation for reflux.
D-LimoneneA compound from citrus peel that has been used for heartburn and reflux20, but the 1 g every-other-day regimen rests on small trials. Claims that it coats the lining, neutralizes acid or helps the stomach empty are unproven.1,000 mg every other dayWith food (cycling protocol: 20 days on, then as needed)Evidence comes from small trials. Bioavailable only when taken with a fat-containing meal.
Magnesium GlycinateMagnesium has mild prokinetic effects on the gut, stimulating gastric emptying and reducing the time food sits in the stomach fermenting. Long-term PPI use is associated with low magnesium in some people; correcting a measured deficiency matters because severe deficiency affects heart rhythm.300 to 400 mg elemental magnesium before bed.Before bedtimeIt can still loosen stools. Avoid it, or take it only on medical advice, if you have reduced kidney function; take it 2 hours apart from bisphosphonate bone medicines, and ask your pharmacist about timing with antibiotics16. The top of this range is above the 350 mg/day upper intake level for supplemental magnesium; above that, diarrhea is common.
Vitamin B12Gastric acid is essential for B12 absorption: it releases B12 from food proteins so the vitamin can later bind intrinsic factor and be absorbed. Long-term PPI use is associated with reduced B12 absorption; deficiency can cause fatigue, neuropathy and mood changes. Sublingual B12 bypasses the need for gastric acid entirely.1,000 to 2,000 mcg/day (sublingual)Morning, dissolve under tongueHigh-dose oral or sublingual B12 can be absorbed without stomach acid. Consider testing if symptoms suggest deficiency.
What to Expect

What to Expect Over Time

Most hiatal hernias need no repair; care centers on the reflux they cause, and surgery is kept for specific situations.

Treatment and supportive care, together
First Weeks

Weight loss, raising the head of the bed, no meals for 3 hours before bed and cutting your own trigger foods come first, with an 8-⁠week course of a proton pump inhibitor when reflux symptoms need it10. A sliding hernia without reflux symptoms is not repaired10.

Months 1 to 3

If once-daily medicine is not enough, twice-daily dosing can be tried, and the aim is the lowest dose that controls symptoms10. A paraesophageal hernia that causes symptoms usually gains little from medicine, and its definitive treatment is surgery10.

Months 3 to 12

Surgery may be considered for a sliding hernia when regurgitation continues despite medicine10; the repair usually includes a fundoplication, and the decision is shared with you14. The self-massage and heel-drop routines that circulate have no trial evidence of moving the hernia4.

Long Term

Long-term acid suppression deserves periodic review rather than being stopped on your own3. After repair, recurrence and side effects such as trouble swallowing and gas bloat are real5.

When to Seek Care

Call 911 or go to the emergency department at once, rather than waiting or trying diet, with sudden severe chest or upper abdominal pain, retching without bringing anything up, sudden inability to swallow or being unable to belch or vomit: the stomach may be trapped or twisted, or it may be the heart9. Call 911 or go to the emergency department for black, tarry stools or vomiting blood. See a doctor promptly for difficulty swallowing, weight loss, vomiting or anemia10.

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Next Steps

Managing a Hiatal Hernia Long Term

Weight, meal timing and a raised head of the bed can reduce reflux symptoms, and any change to long-term medication is a decision to make with your doctor.

Explore LPR (Silent Reflux) โ†’ Explore GERD (Acid Reflux) →

References & Evidence Notes

Each numbered entry below is either a source you can follow or a note setting out what the evidence does and does not support. Both are numbered together so the markers in the text line up.

Last reviewed October 20, 2026. Supplement entries are cross-checked against the NIH National Center for Complementary and Integrative Health and the Linus Pauling Institute Micronutrient Information Center.7 It is worth being clear about what diet can and cannot change. A hiatal hernia is a structural finding: part of the stomach sits above the diaphragm. Diet, posture and weight loss can substantially improve the reflux symptoms a hernia causes, and that is genuinely worth doing. Nothing on this page moves the stomach back through the diaphragm, and no manual technique, self-applied or performed by a practitioner, has been shown in a controlled trial to reduce a hernia. Sudden severe chest or upper abdominal pain with retching and an inability to vomit or swallow can mean a paraesophageal hernia has become obstructed or strangulated, which is a surgical emergency. And persistent reflux is not something to simply live with, because long-standing reflux is what leads to Barrett's esophagus.

  1. On types: sliding hiatal hernia, where the gastroesophageal junction moves above the diaphragm, accounts for the large majority and is closely associated with reflux. Paraesophageal hernia, where part of the stomach herniates alongside a junction that stays in place, is much less common but carries the risk of volvulus, obstruction and strangulation, which is why symptoms differ and why surgical thresholds differ. ↩
  2. On what genuinely helps reflux symptoms: weight loss where relevant has the strongest evidence of any lifestyle measure, followed by raising the head of the bed, avoiding meals within three hours of lying down, and reducing alcohol. Individual trigger foods vary between people and elimination should be personal rather than a standard list. ↩
  3. On acid suppression: proton pump inhibitors treat the acid consequences of reflux, not the hernia. Long-term use is associated with reduced absorption of vitamin B12, magnesium, iron and calcium and with increased enteric infection risk, which is a reason for periodic review rather than for stopping a drug that is treating something, and gastroenterology guidance sets out how that review is done, PubMed 35183361. Stopping abruptly after prolonged use can cause rebound acid hypersecretion, PubMed 38791497; guidance allows either tapering the dose or stopping at once, PubMed 35183361. ↩
  4. On manual and self-applied hernia techniques. Various routines circulate, typically involving drinking water on an empty stomach then dropping onto the heels, and visceral manipulation performed by a practitioner. There is no controlled trial evidence that any of these reduces a hiatal hernia, and the anatomy makes the proposed mechanism implausible: the stomach is not repositioned through the diaphragmatic hiatus by external pressure or gravity. The components that plausibly do help (upright posture, diaphragmatic breathing and a deliberate pause around eating) are worth keeping on their own terms. Diaphragmatic breathing training has some evidence for reflux symptoms, which may be what people are noticing. ↩
  5. On surgery: fundoplication and hiatal hernia repair are effective for selected patients, particularly those with large or paraesophageal hernias, or reflux inadequately controlled medically. Recurrence and side effects including dysphagia and gas-bloat are real and belong in the decision. ↩
  6. On Barrett's esophagus: chronic reflux can cause intestinal metaplasia of the lower esophagus, which carries a small annual risk of progression to esophageal adenocarcinoma. Screening is considered in people with long-standing reflux plus additional risk factors. This is the main reason not to treat persistent reflux as merely inconvenient. ↩
  7. National Center for Complementary and Integrative Health (NIH), nccih.nih.gov, and the Linus Pauling Institute Micronutrient Information Center, lpi.oregonstate.edu/mic. ↩
  8. On the reported harms of long-term proton pump inhibitor use: an umbrella review of 42 systematic reviews, supported mostly by observational evidence, found associations with kidney disease and with Clostridioides difficile infection, concluded there was no association with neurological disease, and rated the certainty of the evidence very low for most outcomes, PubMed 34114655. ↩
  9. On the emergency: a paraesophageal hiatal hernia is the most common defect that lets the stomach twist (gastric volvulus), a closed-loop obstruction that can cut off its blood supply and presents as a surgical emergency with severe upper abdominal pain and retching, PubMed 29939663. ↩
  10. On how hiatal hernia is managed: a 2019 review found that hiatal hernia is caused by raised pressure inside the abdomen, with overweight and older age the key risk factors and multiple pregnancies, past esophageal surgery and stomach removal among others; that sliding hernias make up more than 90% of cases; that lifestyle measures and an 8-⁠week course of a proton pump inhibitor come first for reflux; that paraesophageal hernias respond little to medicine and are treated surgically, urgently when obstructed or twisted; and that sliding hernias without reflux symptoms are not repaired, PubMed 31750430. ↩
  11. On risk factors: a meta-analysis of endoscopy studies found hiatal hernia associated with age over 50 (odds ratio 2.17), a BMI above 25 (odds ratio 1.93) and male sex (odds ratio 1.36), PubMed 21178776. ↩
  12. On hiatal hernia and reflux: studies suggest 50 to 94% of people with gastroesophageal reflux disease have a sliding hiatal hernia; the review also reports that the sliding type makes up more than 95% of cases, that about 55 to 60% of people older than 50 have a hiatal hernia while only about 10% or fewer develop symptoms, that heartburn is the most frequent symptom, and that life-threatening complications such as incarceration are rare, PubMed 32965871. ↩
  13. On heavy work and abdominal fat: in 685 people having routine endoscopy, male sex, age, heavy physical labor and reflux disease were independent risk factors for hiatal hernia, and a genetic (Mendelian randomization) analysis linked waist-to-hip ratio and trunk fat with it, PubMed 40360898. ↩
  14. On surgery: the 2024 surgical guideline suggests routinely adding a fundoplication when a hiatal hernia is repaired, on low-certainty evidence, and stresses shared decision-making, PubMed 39080063. ↩
  15. On trigger foods: the 2022 American College of Gastroenterology reflux guideline notes that in laboratory studies coffee, caffeine, citrus and spicy food had little or no effect on lower esophageal sphincter pressure, though some may still irritate, while alcohol, tobacco, chocolate, peppermint and high-fat foods do lower it, and that few studies show a benefit from avoiding them, PubMed 34807007. ↩
  16. On magnesium safety: people with impaired kidney function are at higher risk of adverse effects from magnesium supplements; magnesium and bisphosphonate bone medicines should be taken two hours apart, and magnesium can reduce the effect of some antibiotics, Linus Pauling Institute. ↩
  17. On zinc and medicines: zinc supplements taken with some antibiotics can reduce the absorption of both, and taking them at least two hours apart should prevent this, Linus Pauling Institute. ↩
  18. On aloe vera for reflux: a 4-⁠week pilot randomized trial in 79 adults with reflux disease compared aloe vera syrup with two acid-reducing medicines and found that it reduced the frequency of all the reflux symptoms assessed and was well tolerated; it was small and short, PubMed 26742306. ↩
  19. On aloe safety: the National Center for Complementary and Integrative Health reports that short-term oral use of aloe gel, up to 42 days, appears safe, that aloe leaf extracts taken by mouth have been linked to cases of acute hepatitis, that oral aloe may lower blood sugar in people with diabetes, and that aloe taken by mouth may be unsafe in pregnancy and while breastfeeding, NCCIH. ↩
  20. On d-limonene: a 2007 review describes its use for heartburn and reflux, attributed to an acid-neutralizing effect and support of normal peristalsis, and reports low toxicity in humans, PubMed 18072821. ↩
  21. On iron-deficiency anemia: British gastroenterology guidelines report that about a third of men and postmenopausal women with iron-deficiency anemia have an underlying cause, most often in the gut; that unexplained iron-deficiency anemia calls for fast-track referral because gut cancers can present this way, often without specific symptoms; and that examining both the upper and lower gut by endoscopy is the standard approach, PubMed 34497146. ↩