Can an adult patient with chest pain, back pain, and jaw pain after eating, relieved by Mylanta (antacid) and omeprazole (proton pump inhibitor (PPI)) and Tylenol (acetaminophen), with a negative esophagogastroduodenoscopy (EGD) for ulcers, have a hiatal hernia as the cause of their symptoms?

Can Hiatal Hernia Cause These Symptoms?

Yes, a hiatal hernia can absolutely cause chest pain, back pain, and jaw pain after eating that responds to antacids and PPIs, even when EGD shows no ulcers. 1, 2

Why Hiatal Hernia Is a Strong Candidate

Your symptom pattern is highly consistent with GERD-related pain from a hiatal hernia:

• Hiatal hernia is explicitly listed as a cause of epigastric pain with reflux-type symptoms in the ACR Appropriateness Criteria 1
• The American Gastroenterological Association specifically recommends alginate-containing antacids (like Mylanta) for patients with known hiatal hernias because these formulations create a protective "raft" that displaces the postprandial acid pocket below the diaphragm 2
• Your response to Mylanta, omeprazole, and the post-meal timing strongly suggests acid-related pathology, which is the hallmark of hiatal hernia complications 2

Understanding the Negative EGD

A normal EGD does not rule out hiatal hernia as the cause:

• EGD in the majority of GERD patients will be normal - the absence of erosive esophagitis or ulcers doesn't exclude reflux disease 1
• EGD should be performed to assess for GERD injury/complications but not as a diagnostic tool to confirm or exclude GERD 1
• Only 26% of GERD patients show esophagitis on endoscopy, and only 42% have abnormal 24-hour pH monitoring 3

The Atypical Pain Pattern Explained

Your chest, back, and jaw pain after eating can be GERD-related:

• GERD symptoms overlap with other conditions and are nonspecific - chest pain radiating to the jaw can mimic cardiac pain but be entirely esophageal in origin 1
• In one study, chest pain was the second leading symptom in adults with esophageal disease, and whether this can be differentiated from GERD remains uncertain 1
• 71% of patients with noncardiac chest pain responded to high-dose omeprazole (40mg twice daily), confirming acid reflux as the cause even when other tests were negative 3

Critical Diagnostic Consideration

You must first exclude cardiac causes before attributing jaw and back pain to hiatal hernia:

• Pain radiating to the back and jaw raises suspicion for myocardial infarction, which must be ruled out with appropriate cardiac workup 1
• Once cardiac causes are excluded, the post-meal timing, relief with antacids/PPIs, and lack of exertional component strongly favor GERD from hiatal hernia 1, 2

Recommended Next Steps

Optimize Current Medical Therapy

• Increase omeprazole to twice-daily dosing (before breakfast and dinner) for 4-8 weeks, as this is the recommended escalation for inadequate response 2, 4
• Add alginate-containing antacids (Gaviscon) after meals and at bedtime - these are specifically recommended for hiatal hernia patients with post-meal symptoms 2
• Ensure proper PPI timing: take 30-60 minutes before meals to optimize efficacy 4

Lifestyle Modifications

• Elevate the head of your bed 6-8 inches for nighttime symptoms 2, 4
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 2
• Weight loss if overweight or obese 4
• Avoid trigger foods (alcohol, coffee, spicy foods, carbonated beverages) 4

If Symptoms Persist After 4-8 Weeks

• Proceed with ambulatory 24-hour pH-impedance monitoring while on PPI therapy to objectively confirm reflux as the cause 1, 4
• Consider esophageal manometry to evaluate for motility disorders 4
• Repeat EGD to specifically look for Cameron ulcers/erosions - these are linear ulcers that occur at the diaphragmatic impression in large hiatal hernias, seen in 5.2% of hiatal hernia patients, and can cause both acute and chronic bleeding 5, 6

Important Caveats

Cameron ulcers are frequently missed on initial endoscopy because they occur specifically at the diaphragmatic pinch point and may require careful examination of the hernia sac 5, 6:

• Cameron lesions present with chronic GI bleeding and iron deficiency anemia in two-thirds of cases, but can also be incidental findings 5
• Multiple Cameron lesions are noted in about two-thirds of cases rather than a solitary erosion 5
• These ulcers heal slowly with medical therapy (median 12 weeks) and have high recurrence rates 5, 6

If optimized medical therapy fails after 8 weeks with confirmed GERD on pH monitoring, surgical referral is appropriate for laparoscopic fundoplication or magnetic sphincter augmentation 4