A hiatal hernia is when the stomach protrudes up into the esophagus. But to describe a hiatal hernia fully, it’s helpful to paint an anatomical picture first.

The esophagus is a long tube that connects the mouth to the stomach. The esophagus passes through an opening (hiatus) in the diaphragm just before connecting with the stomach, which sits below the diaphragm. Normally the stomach and diaphragm have space between them so that the diaphragm can easily expand and contract and we can comfortably breathe.

With a hiatal hernia, the stomach protrudes up into the esophagus, where it passes through the hiatus of the diaphragm. A hiatal hernia reflects the anatomy of the condition—“hiatal” means hole or opening and “hernia” indicates that it is protruding through a hole. As the stomach pushes up against the diaphragm, it causes various symptoms.

Hiatal hernias vary in severity. The most severe cases are life-threatening, and surgery must be done immediately because the stomach is protruding so far above the diaphragm that it can create severe chest pressure, vomiting, and a loss of blood flow to the stomach itself. It’s indisputable that these are life-threatening and surgery is the best treatment. I’m not referring to these cases here. I’m alluding to the milder cases, where symptoms can still be severe and interrupt your ability to do daily activities, but it is not life-threatening.

Often overlooked, mild hiatal hernias are the ones that can be noted in a patient’s medical chart but dismissed as irrelevant to a patient’s unexplained symptoms. There are also sliding hiatal hernias, where the hernia slides up and down, so sometimes the stomach is herniated and sometimes it’s not. If this type of hernia is not herniated at the time of a doctor’s examination, it can be missed even though a patient is affected by its symptoms.

With a hiatal hernia, as the stomach protrudes into the esophagus and pushes against the diaphragm, other organs are impacted, causing a cascade of events and symptoms. Symptoms vary from mild to severe acid reflux to anxiety-provoking heart palpitations and shortness of breath. Here are some of the most common symptoms I come across:

Heart palpitations. As the stomach protrudes into the hernia and pushes against the diaphragm, it causes an elevation of the diaphragm, which can constrict the heart, creating pressure and forcing the heart to work harder than normal. This leads to heart palpitations—the heart pumps very rapidly.

Difficulty breathing and lack of oxygen. The elevation and spasming of the diaphragm is usually accompanied by difficulty breathing or shortness of breath since the diaphragm cannot freely move.

Unfortunately, it’s usually in the middle of the night when this happens. Patients wake up with their hearts pounding, gasping for air and panicking. When they seek emergency help, they’re often told it was a panic attack and prescribed medications that are ineffective.

Patients who are very fit can also become lightheaded while working out or even walking around the house.

Stress and anxiety. When the body is not getting enough oxygen, it triggers fight-or-flight mode, which activates stress hormones and feelings of panic and anxiety. Often patients report this happening in the middle of the night—they suddenly go from a deep sleep to extreme alertness, as they abruptly wake up terrified, gasping for air. As the condition worsens, people can experience severe anxiousness throughout the day for no apparent reason.

Acid reflux. Patients experience acid reflux in different ways. Some have common symptoms like heartburn or GERD. And others don’t have typical symptoms but report waking in the morning with a bitter taste in the mouth or hoarseness, not realizing that this is due to acid reflux—the acid has been crawling up the esophagus into their mouth during the night.

Or the sensation of food being stuck in the esophagus can be experienced as an indication of severe acid reflux or GERD. Patients often say that it feels like food isn’t going down properly.

Bloating and belching. As the stomach pushes up into the esophagus, gas can become trapped in the stomach, so bloating and belching are common symptoms.

Rapid satiety. With a hiatal hernia, the stomach can be smaller because it’s spasming and part of it is protruding upward. People can reach satiety more quickly when this happens, so they need to eat smaller meals throughout the day.

Food sensitivity. Difficulty processing fatty and spicy foods is also common because the stomach is compromised. And undiagnosed food sensitivities, like gluten and dairy, can also contribute.

Anything that puts physical or physiological stress on the stomach, causing it to protrude into the esophagus, can contribute to the development of a hiatal hernia. This could be anything from physical damage from a car accident to the physiological stress of a chronically unhealthy diet. Things like constipation, H. pylori infection, and nerve imbalances to the stomach, diaphragm, and abdominal muscles can lead to a hiatal hernia, too.

There are physical and physiological components to alleviating a hiatal hernia. The physical aspect of the stomach and diaphragm must be addressed to rebalance and create stability after being strained, by spasms and protrusion, over time. Using physical therapy to restore them to a healthy state is important.

Another major part is addressing gut health—evaluating food sensitivities, gut inflammation, the gut microbiome, etc. We also rebalance a patient’s hormones if the stress of the hernia has continued for a long period of time, which can help improve sleep, stress, and anxiety. And if there is a nerve imbalance associated with the hiatal hernia, then repair is directed toward that, too.

Generally, seeing a gastroenterologist who will perform an endoscopy is the best way to determine if you have a hiatal hernia. If you do, working closely with a functional medicine practitioner to ensure that your body gets the realignment it needs, especially nutritional and physical rebalancing, is critical.