My hiatal hernia has gotten bigger, should I stop lifting?

Medical Q&A [Moderated]
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I’ve suffered from GERD all my adult life, but I’ve always managed to control it with PPI medication.

Six years ago I went to gastroscopy and I was diagnosed with a small (<1cm) hiatal hernia. About two years after this I started lifting weights (got started with Starting Strength, after that I’ve done various programs, including some of yours). Now last week I got another gastroscopy and it turned out that my hiatal hernia had gotten larger and was now about 2-3cm. My doctor wouldn’t directly advice me to stop lifting, but said that in his experience, the biggest hiatal hernias among young people are found on people who do some form of weightlifting/gym training. Considering this, I think it’s very probable that me starting lifting weights directly made my hernia worse.

While I can still manage my GERD symptoms by taking PPI (esomeprazole) daily, I’m now afraid to continue lifting in case my hiatal hernia gets even worse and the symptoms get so bad that I can’t control them with medication any more or some new complications arise.

What is your advice? Is it likely that it is weightlifting that made my hernia worse? Should I keep lifting or not?

My doctor also said I could be good candidate for hiatal hernia repair surgery (I suppose this would be Nissen fundoplication). For now, I wouldn’t like to go down this road, but just in case I do at some point, does doing this procedure somehow affect weightlifting?

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I don’t know whether it is “likely” that weightlifting did this, nor can anyone tell you that with confidence. We think that the health benefits of meeting physical activity guidelines, including at least twice-weekly strength training, outweigh these risks/concerns, but that is also our opinion – and others may choose to weigh things differently. I understand that this is not the most direct answer to your questions, but they unfortunately do not have simple answers.

You should be able to continue training after a procedure like that, although as with everything else it’s worth discussing with the surgeon.

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This message in no way implies a patient/provider relationship is being or has been established I am a general surgeon and I do both endoscopies (daily) and Nissen fundoplications (occasionally, when clearly indicated). I would recommend AGAINST stopping your lifting, as the likely impact of even very heavy lifting with a lot of Valsalva on a hiatal hernia (HH) is very low and the benefits of strength conditioning are very high. I would argue that the benefits outweigh the risks. The natural history of HH is that they often slowly expand over time. It should also be noted that there is SIGNIFICANT interobserver variation in the sizing of a HH and you can easily see several centimeters of variation in the reported size depending on who is performing the EGD and at what phase of peristalsis the hernia was measured. These hernias naturally contract and expand rhythmically. Under no circumstances should a patient consider surgical repair of a hiatal hernia unless it becomes a daily impediment to normal eating by causing symptomatic dysphagia or the degree of GERD becomes unbearable and is also unresponsive to maximal medical therapy. I do not offer fundoplication to a patient unless they report continued GERD symptoms on maximal dose therapy of BOTH a PPI and H2 blocker used concurrently. If the patient is diabetic, then a promotility agent such as erythromycin or Reglan should also be trialed. Only then is surgery a consideration. Personally, if I reached the point where I needed surgical correction for GERD, I would investigate the LINX device placed laparoscopically before going to a full blown fundoplication. A fundoplication can be an amazing procedure in the right patient and literally gives them back a normal life, but it typically is the final solution after all others have failed.

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Thank you both for the responses.

he likely impact of even very heavy lifting with a lot of Valsalva on a hiatal hernia (HH) is very low

What do you base this on? I was not able to get a clear answer from my gastroenterologist about this (only that he sees large HHs in people who do lifting frequently). I personally can’t find too much direct research literature on the subject either, but what little I can find suggests that lifting might have an adverse effect on HH [1, 2]. Also, it seems to be a common advice among doctors (although not mine) to limit lifting of weights or other heavy objects with hiatal hernia.

I was not aware that HH can look different size on different images. I have three images from it from my latest endoscopy and I was actually wondering with it looked absolutely huge in one of them (compared to 2-3cm in the other pictures). From the previous endoscopy I have only one image and in it it indeed looks very small (<1cm).

I have no heartburn, which I consider the major symptom from my GERD, while on medication. Sometimes I have feeling tightness of the chest, bloating of the stomach, and other minor symptoms that might or might not be due to GERD, but those never bothered me too much. However, the endoscopy did show small amount of erosion (LA grade A) despite of me being on PPI for a long time. This is why my gastroenterologist suggested that I might want to consider the surgery. Also, I’m still relatively young (34 years) and I could possibly live the rest of my life without the PPI medication if the procedure was performed.

I will discuss this further with my gastroenterologist. I stopped lifting for now, because, frankly, the results of the endoscopy made me really afraid. This was pretty depressing for me especially because my deadlift was progressing really well and I was pretty confident I would break 170kg on my next 1RM attempt.

I was also considering doing some other form of strength training that might be more HH friendly (maybe calisthenics or some form of martial arts) instead of barbell training in the future. I would guess that to meet the health guidelines barbells and heavy weights are not strictly necessary.

[1] The effect of diaphragmatic stressors on recurrent hiatal hernia | Hernia
[2] Journal of Clinical Gastroenterology

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VJJK: I would most certainly encourage you to keep exercising, including resistance training of some kind. What form that takes is entirely up to you, but there simply isn’t data to suggest HH enlarges at any different rate in lifters vs. nonlifters. When physicians or others recommend that people with HH stop lifting, they are demonstrating two things: 1) their ignorance of what happens inside the abdominal and thoracic cavities during lifting and 2) the innate conservative CYA attitude of the Healthcare industry at large.

Most doctors are not weight lifters themselves and have only cursory understanding of what is going on. They know there is an association of straining with hernia development in the groin or at the navel and thus assume it must also affect HH. Body wall hernias at the groin or navel are different in nature than HH; they usually are either congenital and grown slowly over many years or are the result of sudden tears in the muscle and fascia at these sites, sometimes caused by lifting but sometimes by even innocuous activities. Straining frequently can certainly make inguinal or umbilical hernias grow over time, largely because there is no opposing counterpressure pushing back against that point of weakness in the body wall.

The impact of straining on HH growth, however, is more theoretical. COULD constant straining and very high intraabdominal pressures (IAP) increase HH size? Possibly, if done while still breathing regularly; but very unlikely because its hard to lift heavy and breathe totally normally at the same time. We innately Valsalva to help stabilize ourselves during heavy lifts. The reason I told you unlikely in my first reply is because for there to be a significant upward force on the stomach, pushing it out of the abdominal cavity and up into the chest (which would create HH growth), there would have to be increased pressure from below the diaphragm (elevated IAP) without any matching increased pressure from above (intrathoracic pressure, ITP). This is not what occurs during a Valsalva, which is performed while holding one’s breath. By closing the airway, we increase thoracic pressure significantly and this pushes down against the diaphragm. It counteracts the pressure caused by core muscle contraction of the abdominal wall during a strained lift. IAP does typically rise above ITP, but the difference is small and I don’t think that difference is enough pressure to actually make the HH grow (this part is just my opinion, I don’t know exactly how much pressure differential is needed in short microbursts to stimulate HH growth over time, and that’s why I say unlikely rather than simply no way). There is no large pressure differential across the diaphragm, so that obviates the purported mechanism by which heavy lifting would make the HH expand. These Valsalva events during weightlifting are also usually very short duration, a few seconds at most. That is not the kind of pressure currently believed to cause stretching of the connective tissues around the diaphragmatic crura, through which the lower esophagus passes and that have to stretch in order to allow the HH to expand. That kind so stretching is a very slow process in response to constant elevated pressures, most commonly by an obese abdomen creating constant upward pressure against the diaphragm, especially while supine, and/or by frequent gastric distention with large meals. This is why we counsel HH patients to eat numerous smaller meals through the day rather than a few large meals.

You may find this article useful: Systematic review of intra-abdominal and intrathoracic pressures initiated by the Valsalva manoeuvre during high-intensity resistance exercises - PMC. Of note, if you do choose to continue weight lifting, there does appear to be a larger pressure differential across the diaphragm in some movements, such as the leg press, while in others, such as the bench press, there is almost no difference at all. In fact, you create more pressure differential by coughing or sneezing than you do in most weight lifting. So, on balance, I would personally consider the health benefits of weight lifting to outstrip and justify whatever risks might also be present when lifting.

Hope that is helpful.

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Thank you again for the response.

That kind so stretching is a very slow process in response to constant elevated pressures, most commonly by an obese abdomen creating constant upward pressure against the diaphragm, especially while supine, and/or by frequent gastric distention with large meals. This is why we counsel HH patients to eat numerous smaller meals through the day rather than a few large meals.

I’ve never been obese, but I have started eating much larger meals since I started lifting (and I suppose many others do the same), so possibly this could help to explain worsening of my HH.

The link you provided is interesting. It seems that IAP-ITP pressure difference is indeed negative in bench press (i.e. the pressure gradient is towards the abdomen). At least naively this should mean that if I’m afraid that squatting and deadlifting will make my hernia worse, I should also believe that bench pressing will push it back because of the opposite pressure gradient. Personally I don’t know what to believe at this point, but I will probably still consult with my gastroenterologist again and, while waiting, continue at least maintenance level of lifting.