Articles

Evidence based

Evidence Based

This article is based on scientific evidence, written by experts and fact checked by experts.

Our team of licensed nutritionists and dietitians strive to be objective, unbiased, honest and to present both sides of the argument.

This article contains scientific references. The numbers in the parentheses (1, 2, 3) are clickable links to peer-reviewed scientific papers.

Hiatal Hernia Relief Guide: Non-Surgical Strategies

Written by Dr. Michael Ruscio, DC on February 21, 2024

Written by Dr. Michael Ruscio, DC on February 21, 2024 — Reviewed by Aimee Gallo

You Can’t Correct the Atypical Anatomy of a Hiatal Hernia, But These Hands-On Techniques Might Help

• What Is a Hiatal Hernia?|
• Hiatal Hernia Causes|
• Natural Treatments for Hiatal Hernias|
• Lifestyle Changes for Hiatal Hernias|
• Manual Therapies: How Hands Can Help Hiatal Hernias|
• When Is Surgery Recommended?|
• Living With a Hiatal Hernia|

Hiatal hernia is the most common cause of gastroesophageal reflux disease (GERD), or chronic acid reflux 1. In most cases, a GERD patient won’t get a hiatal hernia diagnosis until after they’ve been dealing with reflux issues for a while. That’s because a hiatal hernia isn’t readily apparent without some sort of medical imaging 1.

While a minor case of hiatal hernia may not result in uncomfortable symptoms, the severity can range quite a bit and may even require surgery 1. Although there’s not a ton of research, we do have evidence that natural approaches (such as avoiding certain foods, losing belly fat, taking certain natural substances, trying acupuncture, or doing hands-on treatments) can alleviate the symptoms of a hiatal hernia long-term.

Let’s break down what a hiatal hernia is to help you better understand this condition. Then we’ll go over the treatment options and therapies to help you treat it and try to avoid surgery.

What Is a Hiatal Hernia?

A hiatal hernia occurs when the gastroesophageal junction (where the esophagus meets the stomach) or the fundus (upper part of the stomach) bulges upward through an opening in the diaphragm called the hiatus. Only the esophagus should pass through the hiatus, but when part of the stomach makes it through, too, you’re more likely to have acid reflux and GERD. A hiatal hernia can change the alignment of the lower esophageal sphincter (LES), which keeps stomach acid out of the esophagus. An off-kilter LES makes it easier for acid to reflux upward.

GERD, or chronic acid reflux, is among the most common symptoms of a hiatal hernia, but this structural disorder can also cause 2 3:

• Heartburn
• Regurgitation of partially digested food
• Chronic cough
• Asthma
• Difficulty swallowing (dysphagia)
• Pain just above the belly button
• Chest pain
• Feeling full shortly after eating

There are several different types of hiatal hernia, but the first type is by far the most common 2.

Hiatal hernias are often only discovered during a medical exam that looks for causes of persistent GERD or other upper-abdominal complaints 4. Diagnosis requires imaging (such as an upper endoscopy) because a physical exam can’t detect the anatomical issue happening inside the body 2 3.

Hiatal Hernia Causes

The incidence of hiatal hernia increases as we get older, but only 9% of people with a hiatal hernia have symptoms 2 5. 

A hiatal hernia can be congenital (you’re born with it) or develop over time, often as a result of weakness in the diaphragm or gastroesophageal junction 2. Not surprisingly, some genetic factors may contribute to weakness of the diaphragm or loosen the phrenoesophageal ligament, which attaches the esophagus to the diaphragm. Either inherited issue can lead to a hiatal hernia 2 6. 

For example, while observing patients at the clinic, we’ve noticed that hiatal hernias seem more common in people with hypermobility spectrum disorders, such as Ehlers-Danlos syndrome. Hypermobility spectrum disorders can disrupt connective tissue, weakening muscles like the diaphragm or loosening attachments like the phrenoesophageal ligament 7.

Hiatal hernias are also likely to develop from high abdominal pressure that’s common with pregnancy, chronic constipation, chronic obstructive pulmonary disease (COPD), or obesity 2.

Though plenty of medications can treat the symptoms of a hiatal hernia, a number of studies support the use of natural treatments to address them. Examples include lifestyle changes (like adjusting your diet), taking natural substances, doing breathing exercises, or trying acupuncture or several hands-on (manual) treatments.

Each of these approaches, which I’ll detail next, can help relieve hiatal hernia symptoms, like GERD, even long-term, and help you avoid the need for medications or surgery. Notably, some manual therapies, such as osteopathic treatments, myofascial release, and neuromuscular training, might also help improve the function of the gastroesophageal junction. 

Lifestyle Changes for Hiatal Hernias

Since GERD often accompanies a hiatal hernia, lifestyle changes aimed at improving GERD may be helpful for hiatal hernia patients. Even if lifestyle changes don’t correct the part of your stomach that’s bulged into your esophagus, they can remedy the main symptom—acid reflux—that makes hiatal hernias such a problem. For example, too much acid reflux can damage the lining of the esophagus enough to cause Barrett’s esophagus, a precancerous condition 8. 

To try to avoid going there, simple, science-based lifestyle modifications include:

• Eliminating common trigger foods, like 9 10:
  • Fatty foods
  • Coffee/caffeine
  • Chocolate
  • Alcohol
  • Spicy foods
  • Fried foods
  • Citrus
  • Tomato-based products
  • Alliums (garlic, onion, leeks, chives)
  • Peppermint
  • Carbonated beverages
• Avoiding large meals two to three hours before bedtime 3 11
• Sticking to smaller meals in general 11
• Elevating the head of your bed by at least 8 inches 3 9

Weight loss for Hiatal Hernias

We can’t avoid many of the potential causes of hiatal hernia, but one area over which we have some agency is our weight 3 9. About 15% of people with obesity 12 and 37% of those with morbid obesity 13 have a hiatal hernia. So, taking steps to manage weight, especially around the middle, can go a long way toward preventing or minimizing a hiatal hernia.

At our clinic, we usually start patients on a whole-foods anti-inflammatory diet, such as a Paleo diet. Removing foods that inflame your gut can both help you maintain a healthy weight and improve any gastrointestinal symptoms related to something other than a hiatal hernia. 

For example, an inflamed and leaky gut can cause reflux even if you don’t have a hiatal hernia. An anti-inflammatory diet that helps you lose weight can also treat many gastrointestinal conditions with overlapping symptoms, whether or not a hiatal hernia is present. 

Natural Substances for Hiatal Hernias 

Science-backed substances to consider adding into your daily routine to relieve GERD and hiatal hernia include:

• Alginates: These naturally occurring polysaccharides in seaweed act as a raft-forming agent (in the stomach they become a gel that forms a physical barrier preventing acid from refluxing into the esophagus). Meta-analyses have shown that alginates, like Gaviscon, can be as effective as PPIs for treating GERD 14 15.
• Probiotics: A meta-analysis and a systematic review found that probiotics can reduce GERD-related reflux, regurgitation, nausea, burping, and abdominal pain 16 17. And a small randomized controlled trial suggests that adding probiotics to PPIs for GERD may diminish their negative impact on the gut microbiome 18.
• Iberogast: Several clinical studies have shown this herbal blend can be as effective as the indigestion drug cisapride for treating reflux, heartburn, burping, bloating, abdominal pain, and fullness 19 20 21 22.
• Melatonin: When taken with or without omeprazole (a heartburn medication), a small clinical trial showed this over-the-counter hormone can improve GERD 23.
• Fiber: A clinical trial showed that 60% of GERD patients who took psyllium fiber had complete resolution of their GERD symptoms 24. We need more research to understand the role of fiber in hiatal hernia symptoms, but it’s safe to try. Just go slowly—start with a little (like 3–5 grams) and work your way up.

Diaphragmatic Breathing for Hiatal Hernias

Are you surprised that breathing exercises can help people with GERD? A meta-analysis and a systematic review found that various types of breathing exercises that affect the diaphragm can reduce symptoms, improve quality of life, and reduce the need for medication. Breathing exercises are more likely to help if you have mild GERD and no hiatal hernia, but they might be worth a try in any case 25 26. 

Here’s an example of a diaphragmatic breathing sequence for GERD 27: 

1. Lie on your back and place one hand on your chest and one on your belly.
2. Inhale deeply through your nose for 4 seconds, filling your belly instead of your chest.
3. Hold that breath for 4 seconds.
4. Exhale through your mouth for 8 seconds. 

Once you’ve correctly performed the technique while lying down, you can start doing the exercise while sitting, and then while standing. Ideally, do the sequence 30 times or for 5 minutes three times a day, and each time you have symptoms.

Acupuncture for Hiatal Hernia

If you have a hiatal hernia and are open to acupuncture, it could help. A recent meta-analysis found that traditional needle acupuncture and electroacupuncture can reduce the frequency of symptoms and improve quality of life in GERD patients. Acupuncture might help by regulating motility in the esophagus, which may be especially important in hiatal hernia patients who don’t respond to PPIs 28.

Manual Therapies: How Hands Can Help Hiatal Hernias 

Manual therapies attempt to get the internal anatomy back into the right place by using the hands to manipulate the outside of the abdomen. If the above lifestyle changes haven’t given you enough relief, you might consider trying several different kinds of manual therapy that can help with the symptoms of hiatal hernia. Three science-based methods—osteopathic manipulation, myofascial release, and oral neuromuscular training—require a practitioner, and the other is a self-administered approach with anecdotal support. 

Impressively, a recent case study showed that osteopathic manipulation corrected one person’s hiatal hernia structurally and relieved her symptoms 29 manual therapies generally offer temporary structural improvements (like better diaphragm mobility) and symptom relief. 

Nonetheless, when combined with other natural treatments, manual therapies may give you long-term relief and empower you to help yourself as needed. On that note, I’ll start by describing how to do the hiatal hernia self-adjustment maneuver. 

Hiatal Hernia Self-Adjustment Maneuver

In the clinic, we’ve observed that just one week of performing a hiatal hernia self-adjustment maneuver can improve acid reflux, constipation, and post-meal bloating.

The self-adjustment maneuver involves placing two fingers of each hand about one inch below the sternum and one inch to the left, below the rib cage (this is near the gastroesophageal junction, or GEJ). Then, with the skin taut over your ribs, apply pressure while moving your fingers downward several inches, stopping just above your navel. 

This maneuver may not only help reduce the symptoms of a hiatal hernia, but it may also improve a number of other symptoms, as it did for one of our patients. 

Although she had seen improvements with an anti-inflammatory diet and probiotics, she was still struggling with acne, fatigue, constipation, and chronic pain. Joe Mather, MD, the Medical Director of the Ruscio Institute, had her try self-adjustment for a week, and she started to feel better.

One day Joe’s patient noted that when she swallowed her food, it felt like everything suddenly came into alignment. This indicated that the self-adjustments might have improved the mobility of her diaphragm or the position of her GEJ. After that, her gastrointestinal and non-digestive symptoms gradually improved. 

Our clinical experience suggests the self-maneuver might improve the function of the GEJ for some people. It might also improve the function of the vagus nerve, which travels from the base of the skull to the abdomen and helps regulate digestion 30. Branches of the vagus nerve run along the esophagus through the hiatus of the diaphragm to reach the stomach.

Dr. Joe speculated “that the vagus nerve can become compressed even in small hiatal hernias, leading to poor motility (how foodstuffs move through the gut) and constipation. I have now seen several cases where chronic constipation has significantly improved following this maneuver.”

Although we don’t yet have evidence that the self-adjustment maneuver can correct the anatomical abnormality of a hiatal hernia, it can improve the symptoms.

If you try this maneuver to help resolve your symptoms, do it daily for a week and note any improvements in your symptoms. See if you can feel a difference in your abdominal cavity. Everyone describes the feeling of food moving from the esophagus to the stomach differently. But an improvement might feel like less pressure when you swallow or less fullness up around your left ribs.

All we have is anecdotal evidence supporting the self-adjustment maneuver for hiatal hernia. But it’s somewhat similar to osteopathic treatment of the lower esophageal sphincter, and we do have evidence that osteopathic manipulation can relieve GERD, a major symptom of hiatal hernia. 

Osteopathic Treatment

The osteopathic treatment of hiatal hernia symptoms can vary. In one version, a qualified healthcare provider applies pressure to the area below the patient’s sternum while the patient breathes in and bends forward. The patient then straightens their spine, extends their head back, and breathes out while the physician applies pressure downward 31. Another version might involve an osteopath stretching a patient’s diaphragm while the patient breathes in and out 8 times 32.

To my knowledge, only one study shows it’s possible for osteopathic maneuvers to correct the anatomical abnormality of a hiatal hernia. The recent case study of a 71-year-old female demonstrated that four sessions of osteopathic manipulative treatments returned her stomach position to normal, relieving her of symptoms related to her hiatal hernia 29. That certainly gives me hope, but in the meantime, clinical research demonstrates that osteopathic manipulation can significantly improve the main symptom of hiatal hernias: chronic acid reflux, or GERD. 

In one randomized controlled trial, GERD patients who received two 5-minute osteopathic treatments over two weeks had significantly greater improvements in GERD symptoms compared to the control group 31. 

An earlier study of GERD patients found that those who received osteopathic therapy once had a 9%–27% increase in lower esophageal sphincter (LES) pressure compared to controls. In this case, pressure is a good thing—more of it means less GERD 32.

Neither of these studies tested osteopathic manipulations on patients with hiatal hernia, so we can’t say for sure how these manual treatments affect the anatomical abnormality. However, reduced LES pressure occurs alongside hiatal hernia and is a risk factor for GERD. So, the improved symptoms and increase in LES pressure in these studies suggests that osteopathic treatment might be beneficial for hiatal hernias. 

Another type of hands-on treatment called myofascial release shows promise as well.

Myofascial Release

“Myo” means muscle and “fascial” means the weblike connective tissue that surrounds and supports the muscles and every other type of tissue in the body. Any kind of trauma to the body can cause normally flexible fascia to tighten and lose its elasticity, constraining the movement of organs and tissues in the body 33.

In myofascial release for GERD, a qualified therapist kneads and stretches tight spots on the abdomen to relieve pressure around the diaphragm and gastroesophageal junction (GEJ) 34. 

In one randomized controlled trial, two myofascial release treatments a week for two weeks improved GERD patients’ symptoms and quality of life. The treatments also reduced their need for proton pump inhibitors compared to the control group 34. Although this study did not include patients with hiatal hernias, myofascial release may be able to improve the mobility of the diaphragm and support the position of the GEJ. 

We definitely need more research to understand how this therapy can help specifically with hiatal hernias. Until then, we can at least say it’s worth a try for relieving the GERD that plagues people with this disorder.

Oral Neuromuscular Training

Oral neuromuscular training serves to improve swallowing and reduce pressure at the gastroesophageal junction to relieve the symptoms of a hiatal hernia 35.

A 2018 study tested the effects of oral neuromuscular training in hiatal hernia patients. The participants placed an acrylic oral medical device (IQoro) in their mouths, between their teeth and lips. They then pulled forward on the device’s handle, keeping their lips sealed against the outward pressure. The patients did this for several minutes a day for six months. At the end of the study, most patients, especially those with severe obesity, had an easier time swallowing and fewer GERD symptoms 35. 

Without a placebo or control, this study can’t tell us whether oral neuromuscular training was the definite cause of their improvements. However, these early findings are promising enough to recommend it as something worth trying.

When Is Surgery Recommended?

Most (95% of) hiatal hernias fall into the less severe category. Conventional treatment of hiatal hernias usually consists of over-the-counter antacids (like TUMS), acid blockers (like Pepcid or famotidine), or proton pump inhibitors (PPIs). Some PPIs, like Prilosec or Nexium, are available over the counter, and others, like Dexilant, require a prescription. In rare cases, hiatal hernia surgery may be necessary. 

Surgery is the only proven way of correcting a hiatal hernia, and it’s typically reserved for patients with severe symptoms or large hernias, which can occur in types 2, 3, or 4 1 36. Fundoplication is the most common hiatal hernia surgery. It is a laparoscopic surgery (not requiring large incisions) in which a surgeon wraps part of the fundus (top part) of the stomach around the base of the esophagus. This repositioning reinforces the lower esophageal sphincter to prevent acid or food from coming up into the esophagus 2 3 6. 

Living With a Hiatal Hernia

If you have symptoms suggestive of a hiatal hernia, like frequent acid reflux, feeling too full after eating just a little, abdominal pain, or indigestion, you have many options for feeling better. It’s a good idea to work with a doctor to confirm you have a hiatal hernia. With their support, you can try various natural treatments to see if you can stave off medications or surgery. 

For example, the most common symptom of a hiatal hernia is chronic acid reflux, or GERD, so lifestyle changes aimed at reducing GERD symptoms can go a long way. Taking steps like avoiding common trigger foods, eating smaller meals, eating your last meal several hours before bedtime, and elevating the head of your bed by at least 8 inches are great places to start to see if your symptoms improve.

Similarly, if extra weight around your middle is contributing to a hiatal hernia or GERD, losing weight is a powerful way to back yourself away from both. Not to make weight loss sound easy—it can be extremely difficult for some people who’ve tried everything—but opting for an anti-inflammatory diet that excludes processed foods may be a great starting point. Such a diet can also go a long way toward healing an inflamed and leaky gut that could be contributing to acid reflux, whether or not you have a hiatal hernia. 

Other science-based natural treatments worth exploring include substances like alginates, probiotics, or fiber, diaphragmatic breathing exercises, or acupuncture. These have shown benefits for GERD patients and may improve acid reflux, the most problematic symptom in hiatal hernia patients.

Surgery is still the only proven way of correcting the anatomy of a hiatal hernia. But if diet and other lifestyle changes aren’t helping, you can try hands-on techniques (on your own or with the help of a practitioner) to see whether your symptoms improve. 

A combination of lifestyle changes and hands-on therapies are all viable natural avenues to help you quiet the symptoms of your hiatal hernia and ideally avoid medications or surgery. If you’d like more personalized support, reach out to our clinic. We’d love to help.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.