The diaphragm separates the chest from the abdomen. The oesophagus passes through an opening in this muscle, the oesophageal hiatus, and joins the stomach just below it. Normally, the diaphragm supports the lower sphincter muscle of the oesophagus at this point — together they form the most important barrier against stomach acid flowing back up.¹
In a hiatus hernia, this opening is widened and part of the stomach slides up into the chest. The everyday German term Zwerchfellbruch literally means a “break” in the diaphragm — but “break” here does not refer to a broken bone; it means a hernia, as with an inguinal hernia.
Not every hiatus hernia is an illness. Small sliding hernias are very often found incidentally during gastroscopy and frequently cause no symptoms at all. Conversely, not everyone with reflux has a hernia. That is why treatment is aimed not at the finding but at the symptoms.¹,²
How it differs from reflux disease: a hiatus hernia is an anatomical change that can encourage reflux. Reflux disease itself — that is, heartburn, inflammation of the oesophagus and its treatment regardless of the cause — is covered in the article Heartburn and reflux disease. Here the focus is on what makes the hernia special.
2. Types: sliding hernia and para-oesophageal hernia
The classification is not just a formality — it determines whether a hernia is more likely to be harmless or needs to be monitored.³
Type
What happens
Typical consequences
Type I: axial sliding hernia
The entrance to the stomach slides upwards along the oesophagus
By far the most common type; encourages reflux, otherwise usually harmless
Type II: para-oesophageal hernia
The entrance to the stomach stays in place, and part of the stomach pushes up alongside it
Less reflux, but a feeling of pressure and fullness; rarely strangulation
Type III: mixed type
A combination of both
Often larger hernias with mixed symptoms
Type IV: complex hernia
Besides the stomach, other organs such as parts of the bowel pass into the chest
Rare; in extreme cases the whole stomach lies in the chest (“upside-down stomach”)
Table scrolls to the right
For everyday life this means: the sliding hernia is above all a reflux issue. The rarer types II to IV are more of a mechanical issue — here it is about the space taken up in the chest and the rare but serious risk of strangulation.
3. Symptoms and complications
With a sliding hernia
Heartburn — a burning pain behind the breastbone, often after eating or when lying down
Sour belching and stomach contents flowing back into the mouth
Symptoms at night — reflux when lying down, a cough or hoarseness in the morning
A feeling of pressure in the chest after larger meals
With large and para-oesophageal hernias
A feeling of fullness even after small portions, pressure in the chest or upper abdomen
Shortness of breath after eating, when the stomach takes up space in the chest
Anaemia — small defects in the lining at the edge of the diaphragm can bleed unnoticed and cause iron deficiency anaemia
Possible consequences of long-standing reflux are inflammation of the oesophagus, narrowing due to scarring and what is known as Barrett's oesophagus, a change in the lining that can rarely turn into cancer and is therefore checked regularly.¹
Emergency: chest pain and strangulation. Pressure or pain behind the breastbone is always first and foremost a heart issue. With sudden, severe chest pain that spreads, shortness of breath or cold sweats, call 112 (emergency number in Germany) immediately — a heart attack must be ruled out. With a known large hernia, severe pain in the chest or upper abdomen, retching without vomiting and being unable to swallow at all are signs of strangulation or a twisted stomach (gastric volvulus). This is also an emergency.
4. Causes and risk factors
A hiatus hernia usually develops over years through an interplay of tissue giving way and pressure from below:²,³
Age — connective tissue and the muscles of the diaphragm become slacker, and the opening widens.
Increased pressure in the abdomen — from excess weight, especially around the abdomen (see Obesity), pregnancy, a chronic cough or frequent hard straining with constipation.
Congenital factors — an opening in the diaphragm that has been wide since birth; rare in children.
Previous procedures — operations on the entrance to the stomach or on the diaphragm.
Medicines as amplifiers. Medicines do not cause a hernia, but they can make reflux worse or irritate the oesophagus directly. Medicines that can relax the sphincter include calcium channel blockers such as amlodipine, nitrates, medicines with anticholinergic effects, theophylline and benzodiazepines. The lining is irritated by anti-inflammatory painkillers, aspirin, bisphosphonates, some antibiotics such as doxycycline, and potassium and iron tablets — especially if they are swallowed lying down or with too little water. Do not stop any of these on your own: raise the connection at your practice or pharmacy. More in the guide Stomach problems from medications.
5. Diagnosis
A hiatus hernia is often discovered during a gastroscopy that is actually being done because of heartburn or upper abdominal symptoms. Depending on the question, further tests are added:¹,³
Consultation: the type, timing and triggers of the symptoms, changes in weight — and all medicines, including over-the-counter ones.
Gastroscopy (upper endoscopy): shows the hernia, inflammation, narrowing and Barrett's lining; tissue samples are taken if needed.
Barium swallow X-ray: makes the position and size visible, especially with para-oesophageal hernias.
CT scan: for large hernias, for planning surgery or in an emergency.
Oesophageal pressure measurement (manometry): before surgery, to rule out motility disorders of the oesophagus.
24-hour pH monitoring: measures whether and how often acid flows back up — important when symptoms are unclear or surgery is being considered.
Blood count and iron levels: with tiredness, paleness or a large hernia, to detect hidden anaemia.
If you have chest symptoms, you should also have your heart checked before everything is blamed on the hernia. How to prepare for the appointment is shown in the guide Prepare for a doctor's appointment.
6. Treatment: wait and see, lifestyle, medication
No tablet and no exercise will make the hernia itself disappear. The good news: with most sliding hernias, that is not necessary either. If there are no symptoms, there is no treatment. With reflux symptoms, treatment largely follows the recommendations for reflux disease.¹ Which level is right for you is decided by the treating practice.
FoundationTargeted lifestyle changes
Losing weight
If you are overweight, one of the most effective single measures against reflux, because the pressure on the entrance to the stomach falls.
Raise the head of the bed, no late meals
Useful for symptoms at night: raise the head end of the bed and have your last meal a few hours before going to sleep.
First lineReducing acid
Proton pump inhibitors (PPIs)
For example pantoprazole or omeprazole. Initially for a few weeks, then reduced to the lowest effective dose or to taking them only when needed.
Alginates and antacids
Alginates form a protective layer on top of the stomach contents, antacids neutralise acid. Both work quickly but briefly — good for occasional symptoms, but usually not enough as long-term treatment.
Selected casesSurgery
Hiatal repair with fundoplication
The opening in the diaphragm is narrowed and a cuff made from the stomach wall is wrapped around the lower oesophagus. When this makes sense is explained in section 8.
Important for your expectations: with a large sliding hernia, acid blockers work against the burning but not against the backflow itself. If you mainly suffer from regurgitation, that is, stomach contents coming back up into your mouth, PPIs often help less than hoped.¹
7. Acid blockers in practice
Proton pump inhibitors are among the most frequently prescribed medicines — and among those most often taken for longer than necessary. Both also apply to hiatus hernia.⁴
Taking them correctly: usually before breakfast, depending on the product about half an hour to an hour beforehand, because PPIs block the acid pumps best when these are activated by a meal. Taking them just before going to sleep is considerably less effective.
Interactions: omeprazole can weaken the effect of clopidogrel; pantoprazole is then often used instead. Medicines that need stomach acid to be absorbed can also be affected.
Long-term use: in observational studies, taking them for years has been linked with vitamin B12 and magnesium deficiency, bone fractures and certain bowel infections. Whether the acid blockers are the cause has not always been proven — a reason for regular review, not for panic. More in the guide Medications and osteoporosis risk.
When long-term treatment is right: with severe inflammation of the oesophagus or Barrett's lining, long-term use usually makes sense and is intended.
Do not stop abruptly — but do not carry on without a review either. After several weeks of use, stopping suddenly can lead to a temporary overshoot in acid production, known as rebound. The symptoms are then stronger than before for a few weeks — and are easily misread as proof that you cannot manage without the tablet. A step-by-step reduction agreed with the practice is better. With Barrett's lining or severe inflammation, the rule is: do not stop on your own at all. More in the guide Stopping medications.
Reducing acid blockers without ending up with rebound?
brite keeps track of your reduction plan and records how your symptoms develop.
The old rule was: every para-oesophageal hernia must be operated on. Today this rule has been relaxed. The decision depends on the type of hernia, the symptoms, age and other conditions, and is made together with an experienced surgical practice.¹,³
Clear indicationSurgery recommended
Strangulation or twisted stomach
An emergency — surgery is carried out as quickly as possible.
Large hernia with symptoms
Para-oesophageal or mixed hernias that cause difficulty swallowing, a feeling of fullness, shortness of breath after eating or anaemia.
Weigh upSliding hernia with reflux disease
Confirmed reflux despite treatment
If acid blockers are not enough or not tolerated, or if regurgitation is the main problem — and pH monitoring and manometry have confirmed reflux as the cause.
Wanting to be independent of tablets
An understandable reason, but one that has to be weighed against the risks of surgery.
Usually not neededMonitoring
Small sliding hernia without symptoms
An incidental finding, no treatment.
Para-oesophageal hernia without symptoms
Especially in older people, waiting and seeing is often justifiable today, as long as the warning signs are known.
What happens during the operation — and afterwards
The procedure is usually done as keyhole surgery (laparoscopy). The stomach is moved back into the abdomen, the opening in the diaphragm is narrowed with stitches and usually a fundoplication is added — a full or partial cuff made from the stomach wall wrapped around the lower oesophagus.
You should be realistic about three points: in the first few weeks, difficulty swallowing is common and usually settles. Some people find it harder to burp afterwards and have more bloating. And particularly large hernias can come back over the years. Before the procedure, the practice will clarify how blood thinners are to be handled — see Medications before surgery. Afterwards, large tablets may be hard to swallow for a while; your pharmacy can tell you whether they may be split or whether there are liquid alternatives.
9. What helps and what is not backed by evidence
A lot of advice circulates about hiatus hernia. A sober assessment:¹,²
Measure
The idea behind it
Assessment according to current evidence
Raising the head of the bed
Gravity against reflux at night
Useful for symptoms at night
Sleeping on your left side
The entrance to the stomach is then higher than the stomach contents
Small studies suggest less reflux at night; simple and low-risk
Cutting out coffee, chocolate, citrus and spicy food across the board
Typical reflux triggers
Only useful if you notice a clear connection yourself; general bans are not backed by evidence
Diaphragm and breathing training
Strengthening the muscles around the entrance to the stomach
First small studies, limited evidence; does no harm
Manually “pushing the stomach back”
Repositioning the hernia from the outside
No reliable benefit; a hernia cannot be fixed permanently this way
Bicarbonate of soda and home remedies as a long-term solution
Neutralising acid
Short-term at most; bicarbonate of soda supplies a lot of sodium and is not a long-term treatment
Table scrolls to the right
10. Everyday life with a hiatus hernia
Smaller meals — a full stomach pushes upwards more strongly than several small portions.
Stay upright after eating — do not lie down straight away, do not bend over deeply, no tight belts.
Avoid straining — treat sluggish digestion, see Constipation; do not overdo bearing down with your abdominal muscles when lifting.
Swallow tablets upright and with a full glass of water — that way irritating active substances do not get stuck in the oesophagus. Details in the guide How to take medications.
Note down your symptoms — when, how severe, after which meal. This shows whether reducing a PPI is working and helps with the question of surgery.
In the vast majority of cases, a hiatus hernia is not a dangerous finding but an anatomical weak spot that you can live with well. New warning signs — difficulty swallowing, unintended weight loss, anaemia, vomiting blood or black stools — should, however, be checked promptly.
Which meal, which tablet, which burning?
Record symptoms and doses over time — for your next consultation at the practice.
In most cases, no. The common axial sliding hernia is often an incidental finding and at most encourages reflux. The rarer para-oesophageal hernias can become strangulated in exceptional cases; sudden severe pain in the chest or upper abdomen with retching and inability to swallow is then an emergency.
The widened opening in the diaphragm does not close by itself. The symptoms, however, can often be improved considerably, for example through weight loss, adjusted eating habits and acid blockers. Many people live with a small hernia without any restrictions at all.
Usually not. Surgery is recommended mainly for strangulation, for large hernias with symptoms and for confirmed reflux that cannot be treated adequately with medication. Small sliding hernias without symptoms do not need any treatment.
For as long as necessary, but at the lowest effective dose. With severe inflammation of the oesophagus or Barrett's lining, long-term treatment usually makes sense. Otherwise it should be checked regularly whether a reduction or taking them only when needed is possible, step by step rather than abruptly.
Yes, large hernias in particular can cause pressure in the chest and shortness of breath after eating. Chest symptoms should, however, always be checked from the heart side first, before they are put down to the hernia. With sudden severe chest pain, call the emergency number 112.
With reflux at night, a raised head end of the bed and having the last meal a few hours before sleep help. Small studies also suggest that lying on the left side reduces reflux at night. These measures are simple and low-risk.
A hiatus hernia is an anatomical change in the diaphragm that can encourage reflux. Reflux disease describes the symptoms and damage to the lining caused by stomach contents flowing back up. The two often occur together, but not every hernia causes reflux and not every case of reflux is caused by a hernia.
German S2k guideline on gastro-oesophageal reflux disease and eosinophilic oesophagitis, German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS), 2023 — German source. awmf.org
Gesundheitsinformation.de, German Institute for Quality and Efficiency in Health Care (IQWiG): Heartburn and reflux disease. Accessed 2026 — German source. gesundheitsinformation.de
Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or treatment. Sudden severe chest pain always needs to be checked immediately (112, emergency number in Germany); with a known large hernia, severe upper abdominal pain with retching and inability to swallow is an emergency. Do not stop acid blockers abruptly after taking them for a long time, and do not stop prescribed medicines on your own. The choice of medicine and its dose is always set individually by the treating practice. Last updated: September 2026.
