This article is for general education. It does not replace advice from your own doctor, who knows your history and your test results.
A hiatal hernia means part of your stomach has pushed up through an opening in your diaphragm and into your chest. Many people first see it named on a report from tests for heartburn, chest pain or belly pain, such as a barium swallow or upper endoscopy. On its own, a hiatal hernia rarely causes symptoms. One that causes no symptoms or problems needs no treatment.
If your report says small hiatal hernia and nobody explained it, ask about the type of hernia too, because size labels vary from test to test. Sliding hernias are by far the most common kind. The rarer paraesophageal types can twist, block the stomach or cut off its blood supply.
We write as the editorial team at Craft Body Scan, which offers a full body scan at each of its centers. A hiatal hernia often turns up on scans done for other reasons. This guide also covers what a CT can and cannot show, and which test answers the question better.
Hiatal Hernia at a Glance
- Type and size both count. Doctors weigh the type, the size and your symptoms.
- Size depends on the test. Each test uses its own cut-off.
- Reflux drives symptoms. Heartburn and regurgitation are the typical signs.
- Treatment steps up. Daily habits come first, then medicine, then surgery for some.
What a Hiatal Hernia Is and Who Gets One
The lower esophageal sphincter and the diaphragm are what most often keep stomach contents from flowing back up, according to the NIDDK page on reflux symptoms and causes. A hiatal hernia, also called a hiatus hernia, can raise the chance of GERD or make its symptoms worse. GERD is reflux that keeps causing bothersome symptoms or leads to complications over time.
Hernias that push through the belly wall, such as inguinal ones, are a separate problem, covered in our guide to how scans find abdominal wall hernias. The cause of a hiatal hernia is often unknown. Weak muscles around the opening may play a part, and sometimes an injury or a birth defect does. Risk climbs with age, and obesity and smoking raise it too.
The MESA study of chest CT scans covered 3,179 US adults aged 53 to 94. None had known cardiovascular disease at enrollment. A hiatal hernia showed up in 9.9% of them, a share that rose from 2.4% of people in their 50s to 16.6% of those in their 80s.
The Four Types of Hiatal Hernia
Hernias fall into four types by what has moved above the opening, a system the current SAGES guideline on hiatal hernia surgery uses. Types II, III and IV are grouped as paraesophageal hernias. With these, the stomach can twist, become blocked or lose its blood supply, which a 2019 review calls their main risk. The shares below come from that review, a 2008 review and the MESA CT study.
| Type | What moves | How common | Why it matters |
|---|---|---|---|
| Type I (sliding) | The junction of the esophagus and stomach slides above the opening. | More than 90% of hiatal hernias, per the 2019 review. | Often tied to reflux. Small ones may not show on CT. |
| Type II (paraesophageal) | The top of the stomach pushes up while the junction stays put. | With III and IV, at most 5% to 15% (review). | It can twist or block, and surgery is indicated once it causes symptoms. |
| Type III (mixed) | Both the junction and part of the stomach sit above the opening. | 29% of hernias found on chest CT in MESA. | It counts as paraesophageal, and the MESA authors judge that CT probably finds every Type III hernia. |
| Type IV (other organs) | Another organ, such as small bowel, colon or spleen, rises with the stomach. | Counted within the Types II to IV share. | Its surgical care falls under the SAGES guideline for Types II to IV. |
A note on size. No standard small, moderate or large scale exists for hiatal hernias. Size cut-offs such as 2 cm depend on the test used.
These shares come from studies with different methods and populations, so they are not directly comparable with each other. MESA, a chest CT study of US adults aged 53 to 94, found only Types I and III. CT may miss small sliding hernias, its authors caution. Management decisions may differ by hernia type and size, according to the ACG reflux guideline.
What a Small Hiatal Hernia on Your Report Means
The word small on a report has no single meaning, because each test draws its own line. A sliding hernia is readily diagnosed by barium swallow, endoscopy or manometry once it spans more than 2 cm, a 2008 review explains. Below that size, only high-resolution manometry finds the gap reliably. This test measures how far the esophageal sphincter sits from the diaphragm.
Other cut-offs come from single studies. One 2018 study used manometry to call a hernia small when the gap ran over 1 cm and up to 2 cm, and large past 2 cm. On CT, the MESA team counted a hernia only when stomach folds reached more than 2 cm above the diaphragm.
Size estimates for a Type I, or sliding, hernia on barium swallow or endoscopy carry an inherent 2 cm error, the 2008 review explains. Too much air during endoscopy can make a hernia look bigger. Barium readings of sliding hernias under 3 cm are unreliable unless a strict protocol is followed. The junction moves so much that a standard way to measure it has been hard to set.
Size is one input among several. If a hiatal hernia causes no symptoms or problems, you do not need treatment for it, according to the MedlinePlus health topic page. A sliding hernia without symptoms can be managed without surgery, a 2020 expert review adds. The SAGES guideline bases management on type, size and how severe the symptoms are, so ask your doctor which type yours is.
Hiatal Hernia Symptoms and What Causes Them
Pain and discomfort come from acid, air or bile flowing upward, MedlinePlus explains. Reflux is the most typical sign, felt as heartburn and regurgitation. Heartburn is a painful burn in the middle of the chest, behind the breastbone, rising from its lower tip toward the throat.
The MedlinePlus hiatal hernia page also lists heartburn that gets worse when you bend over or lie down, along with chest pain and trouble swallowing. Upper belly pain and chronic iron deficiency anemia are less common, the 2019 review notes. A large hernia can make you feel full early in a meal, or cause slow bleeding and iron deficiency anemia.
Paraesophageal hernias follow their own pattern. Pain in the upper belly or behind the breastbone leads the 2008 review’s list of common symptoms, which also names fullness after meals, nausea and retching. Some people sent to a surgeon with a supposedly symptom-free hernia have shortness of breath or trouble with exercise, the SAGES panel notes. The hernia itself could be the cause, in the panel’s view.
Reflux chest pain can be impossible to tell apart from heart pain, the ACG reflux guideline warns. Heart disease should be ruled out first when chest pain comes without heartburn. Our guide to what causes chest pain and when to get help lists the warning signs to know before anyone blames a hernia.
When to Call 911
Call 911 or your local emergency number if any of these signs appear.
- Crushing chest pressure. Sudden crushing, squeezing or tightening in the chest, which MedlinePlus lists as a reason to call 911.
- Pain that spreads. Chest pain that reaches the jaw, the left arm or the area between the shoulder blades.
- No gas or bowel movements. With nausea and vomiting, these can signal a hernia that has been closed off and needs surgery right away, MedlinePlus says of hernias in general.
A twisted stomach, or acute gastric volvulus, is an uncommon complication of large paraesophageal hernias. Its classic signs are vomiting, upper belly pain and a stomach tube that doctors cannot pass, though a 2025 review found that full pattern in fewer than 70% of cases.
The NIDDK advises seeing a doctor for vomiting that will not stop, problems swallowing or vomit that looks like coffee grounds. With a known giant paraesophageal hernia, symptoms that keep building call for repair soon, according to a 2020 expert review, since they may signal that the hernia is becoming trapped.
Which Test Answers Which Question
Each test for a hiatal hernia answers a different question, so your doctor may order one even after a CT. Barium swallow, endoscopy and manometry are rarely done in people without symptoms, the MESA authors note.
A barium swallow or endoscopy still has work to do after a CT, such as showing where the junction sits or whether reflux has damaged the lining. High-resolution manometry is the test for the small gaps a CT can miss.
Our full body scan is a low-dose CT of the heart, lungs and abdomen, with a coronary artery scan, a chest scan and an abdomen and pelvis scan. Results are prepared by our team of board-certified radiologists, who review the images for early signs of cancer and heart disease. Our guide to abdominal CT scans explains what the abdominal part looks at.
The scan uses no contrast or swallowed barium, so it is not a barium swallow and cannot show how the junction moves. We do not offer it as a test for hiatal hernia or as a stand-in for the tests your doctor may order.
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How Hiatal Hernia Treatment Steps Up
Treatment targets symptoms, and it starts with daily habits. For a hiatal hernia that causes symptoms, MedlinePlus suggests smaller meals and not lying down or bending over right after eating. Losing weight and not smoking are on its list too. So is raising the head of the bed 4 to 6 inches.
Weight loss for people who are overweight or obese is a strong recommendation in the ACG guideline on reflux disease, backed by moderate evidence. Its weaker, conditional suggestions include skipping meals in the 2 to 3 hours before bed. Raising the head of the bed for nighttime symptoms is another.
When habits are not enough, medicine comes next. In ACG’s terms, medical care means lifestyle change plus medicines that reduce stomach acid. Surgery may be needed if those do not help, though only rarely, MedlinePlus says. For reflux disease confirmed by testing, especially with a large hiatal hernia, antireflux surgery by an experienced surgeon is a long-term option in the ACG guideline.
Surgery has its own costs, with complications more likely than with medicine, the NIDDK notes. Paraesophageal hernias follow a different path. Surgery remains their definitive treatment, and symptoms count as a reason to operate in the 2019 review. A blocked or twisted stomach calls for urgent surgery.
For paraesophageal hernias without symptoms, Types II to IV, the 2024 SAGES guideline found too little evidence for firm rules and offered expert opinion. Its panel suggests select patients may be offered repair, with criteria. The panel calls for a frank talk because surgeons cannot predict who gets a twisted stomach. If testing finds nothing concerning and the patient accepts that risk, the panel considers watchful waiting reasonable.
Common Questions About Hiatal Hernia
Can You See a Hiatal Hernia on a CT Scan?
Yes, a CT of the chest and abdomen can show a hiatal hernia, though it is not the routine test for one. For a paraesophageal hernia, CT helps doctors judge whether the stomach has twisted. Dallemagne and colleagues, cited in a 2019 review, recommend CT to rule out complications such as a perforation, or hole. Small sliding hernias are the ones a CT may miss.
Can a CT Scan Miss a Hiatal Hernia?
It can, mainly with small sliding hernias. The MESA authors, who studied chest CT in US adults aged 53 to 94, write that CT may miss small sliding hernias found at surgery or on high-resolution manometry. They also judge that CT probably identifies every Type III, or mixed, hernia.
What Is the Best Imaging for a Hiatal Hernia?
No single test is best for every question. A 2018 study of 100 surgical patients at one center, 53 with a hernia, tested manometry, endoscopy and barium X-ray, but not CT, against measurement during the operation. Manometry found 94.3% of hernias and correctly cleared 91.5% of people without one. Endoscopy found 96.2% but cleared only 74.5%, and barium X-ray found 69.8% while clearing 97.9%.
Where Is Hiatal Hernia Pain Located on a Woman?
Usually in the middle of the chest behind the breastbone, where heartburn burns, or in the upper belly, a common pain site with paraesophageal hernias. Guidance does not describe a different pain location for women. In the MESA chest CT study of US adults aged 53 to 94, a hernia appeared in 12.7% of women and 7.0% of men. New chest pain needs heart causes ruled out first.
Can a Small Hiatal Hernia Get Bigger or Go Away?
Both can happen, though the evidence is limited and not specific to small hernias. In the MESA study, 81 people with a hernia had a second CT over 10 years of follow-up. Five of them, or 6.3%, saw it resolve without treatment. Higher body mass index was linked with hernias growing over the same decade.
What Is a Paraesophageal Hernia?
It is a hiatal hernia of Type II, III or IV, where the top of the stomach or another organ rises above the opening. Experts disagree on when one counts as giant, with some using 30% of the stomach in the chest and others 50%. Very few people with a giant one are truly symptom-free, a 2020 review says.
When Is Hiatal Hernia Surgery Needed?
Surgery comes up when habits and medicine fail, or when a paraesophageal hernia causes symptoms. Timing matters, because an emergency repair carries more risk of complications and death than a planned one, the 2020 review notes. For paraesophageal hernias with minimal symptoms, two of three modeling studies summarized in the SAGES guideline favored watchful waiting.
Questions to Bring to Your Doctor
Bring your report and these questions to your next appointment.
- Which type is it? Is my hernia sliding, paraesophageal or mixed?
- How was it measured? Which test found it, and what size cut-off did that test use?
- Is it behind my symptoms? Could my heartburn or swallowing trouble come from it, or from something else?
- Do I need another test? Would a barium swallow, endoscopy or manometry answer a question my scan could not?
- What is the plan? Should I change daily habits, try acid-reducing medicine or see a surgeon?
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