Can a hiatal hernia cause pain?

Hiatal Hernia and Pain

Yes, hiatal hernias can definitely cause pain, with symptoms varying based on the type and size of the hernia. 1 Pain is one of several potential symptoms that patients with hiatal hernias may experience, along with heartburn, regurgitation, and dysphagia.

Types of Hiatal Hernias and Associated Symptoms

Hiatal hernias are classified into four main types:

1. Type I (Sliding) - 83-90% of cases:

   • Most common type
   • Gastroesophageal junction and part of stomach slide above diaphragm
   • Symptoms often mimic GERD due to lower esophageal sphincter laxity 1, 2

2. Type II (Paraesophageal) - ~4% of cases:

   • Gastric fundus herniates while gastroesophageal junction remains in place
   • Can cause more severe symptoms 1, 2

3. Type III - ~11% of cases:

   • Combination of Types I and II
   • Both gastroesophageal junction and fundus herniate 1, 2

4. Type IV - ~1% of cases:

   • Large defect allowing other organs (colon, spleen) to herniate
   • Most severe form 1, 3

Pain Manifestations in Hiatal Hernia

Pain from hiatal hernias can present in various ways:

• Chest pain that may mimic cardiac conditions 4, 5
• Epigastric discomfort or pain in the stomach region 6
• Esophageal pain particularly during swallowing 6
• Pain exacerbated by eating, especially large meals
• Pain worsened by lying down or bending over

Diagnostic Considerations

When evaluating pain potentially caused by hiatal hernia, several diagnostic approaches may be used:

• Upper GI barium studies (80% sensitivity for detecting reflux esophagitis) 1
• Biphasic esophagram (88% sensitivity for detecting esophagitis) 1
• Esophagogastroduodenoscopy (EGD) for direct visualization 6
• Chest X-ray (sensitivity of 2-60% for left-sided hernias) 1
• CT scan (gold standard for confirming diagnosis) 1

Management of Painful Hiatal Hernias

Treatment should follow a stepwise approach:

1. Medical Management (First-Line)

• Lifestyle modifications and PPI therapy are recommended as initial steps 1
• PPI therapy should be taken 30 minutes before meals
• Double-dose PPI may be considered if symptoms persist
• Alginate antacids can be added for breakthrough symptoms 1
• Adjunctive therapy based on symptom pattern:
  • Baclofen for regurgitation
  • Prokinetics if gastroparesis is present
  • Neuromodulators for esophageal hypersensitivity 1

2. Surgical Management

Indicated when:

• Medical management fails
• Symptoms significantly impact quality of life
• Complications develop

Key surgical principles include:

• Complete excision of hernia sac
• Ensuring at least 3 cm of intra-abdominal esophageal length
• Crural closure with non-absorbable sutures
• Mesh reinforcement for defects >3 cm 1, 7

Surgical approaches:

• Laparoscopic repair (preferred approach) 7
• Fundoplication tailored to esophageal motility 1
• Magnetic sphincter augmentation as an alternative option 1

Important Clinical Considerations

• Hiatal hernias can masquerade as cardiac conditions in the emergency department, causing chest pain that mimics angina 4
• Asymptomatic hiatal hernias become symptomatic at a rate of approximately 1% per year 7
• Watchful waiting is appropriate for asymptomatic hernias 7
• Pain relief is often immediate following successful surgical repair 5
• Alternative treatments like osteopathic manipulative treatment have shown promise in some case reports 6

Potential Complications

• Incarceration or volvulus (rare but serious)
• Organ ischemia
• Respiratory compromise due to compression of lung tissue
• Significant impact on quality of life through persistent pain and discomfort 1

Proper diagnosis and management of hiatal hernias can significantly improve patient outcomes and quality of life by effectively addressing the pain and other associated symptoms.