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

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?

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.

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.

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

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.

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.

Hi there ecophotog. Sorry to butt in on such and old post. I dont wanna bother your but Im kinda desperate. I also have a hiatial hernia and I was wondering if you could give me some advice as I saw you were a surgeon who has experience with this sorta thing. My hernia is preventing me from eating any solid food at all as I regurgitate all my food despite months of max ppi use. My gi wont schedule me for surgery because I do powerlifting (not that im any good at, im pretty weak). He thinks it will put me at risk after the surgery. Tbh I really just wanna get back to eating food and powerlifting again as im feeling really frustrated as this is the 3rd gi now who shares the opinion of no more powerlifting if you wanna have the surgey. I saw you recommended a linx which im not sure what it is. But currently they all want me to have some sorta wrap thing done again not too sure. All I know is I hav a sliding grade 3 hiatial hernia and it really is messing up my stuff right now. Sorry if this is too big a ask I totally understand but I was just wondering what kind of procedure I could get that would enable me to keep lifting and what to tell my gi’s. So i can begin eating solid food again without sacrificing powerlifting or any exercise in general. Thanks so much

Hello, Goff25. I 'm sorry to hear about your predicament. While I cannot give you individualized medical advice, I can discuss some of the general principles around hiatal hernia repair and I hope you will find those helpful. They may inform your decisions and help focus future discussions with medical care providers.

A long reply follows below; TL,DR Summary: Find a surgeon who understands the importance of weightlifting and seek care from them.

As you know, a hiatal hernia describes the malposition of the gastroesophageal junction. The GEJ normally sits well below the diaphragm, but when a hiatal hernia forms that junction slides up into the lower portion of the chest and pulls the upper portionof the stomach up with it, out of its normal position. This can result in problems with swallowing solids. More commonly it results in severe acid reflux symptoms. Medications to reduce the amount of acid secreted by the stomach can help control the reflux symptoms but will do nothing to fix the problem with swallowing solids, which occurs because the portion of stomach that is out of position creates an antechamber, sort of shaped like an hourglass but with a much smaller upper portion, that can fill with food but still has a relatively small exit into the main body of the stomach. Once that chamber is full it creates a lot of discomfort, that will not abate until the patient either regurgitates or the solids managed to slip into the main chamber of the stomach.

Not all hiatal hernia require repair. Those that are asymptomatic and small can be observed. Once the hernia contains more than 1/3 of the total stomach volume it should be repaired whether symptoms are present or not. In between a hernia that size and a smaller one is a gray zone that Requires a lot of discussion between the patient and surgeon with regard to expectations For treatment outcomes. It comes down to degree of symptoms and other comorbidities and overall patient willingness to accept the possible consequences of surgery. for example, people who want surgery because they don’t want to take acid expressing medication’s should understand that only a small portion of patients are ever able to completely discontinue their medication’s after the surgery. Most people will still require acid suppression for long-term control of gastritis or ulcer disease. Lifestyle changes are needed after a hiatal hernia repair, such as avoidance of carbonated beverages and significant reduction or abstinence from alcohol.

A hiatal hernia can be caused by several factors, often multiple are present in the same patient. Obesity is the number one cause, with the excess weight of a large abdomen continuously pushing up on the stomach, the surrounding connective tissues slowly stretch over time, leading to pushing the stomach up into the posterior part of the chest just like squeezing a tube of toothpaste. Genetics certainly plays a role, particularly in the degree of flexibility in an individuals connective tissues, which can predispose to forming All kinds of hernias more easily. People who routinely engage in a Valsalva maneuver will experience Increased abdominalpressures and over time Such pressures could theoretically contribute to developing a hiatal hernia. This is why some surgeons may say that weightlifting is a relative contraindication to hiatal hernia repair. However, it is absolutely possible to do a durable and lasting repair in an obese patient with continuous high abdominal pressures and a well done repair should similarly be durable in a weightlifter once it has had adequate time to heal postoperatively. It is imperative with all hernia repairs that an adequate postoperative window is observed where there is no heavy lifting and every effort is made to avoid constipation, severe coughing, or other activities that will create large amounts of intra-abdominal pressure that strain the healing tissues. I know that Dr. Feigenbaum and Dr. Baraki assert the general prescription of a 4 to 6 week window without heavy lifting is arbitrary but the surgical community would disagree. wound healing is a complex process and discussing it is beyond the scope of this reply, but it marches along in an orderly and sequential fashion. Every wound goes through a series of successional steps from hemostasis to inflammation to matrix proliferation and then ultimately to wound remodeling. in the final remodeling phase the initial fibrin matrix is slowly replaced by collagen fibers and other tissue components to give the healed wound strength and function. While remodeling can take months to fully complete, the wound achieves a reasonable amount of strength and durability by about four weeks postoperatively in the average person with decent nutrition and normal tissue quality. I advise patients to avoid any abdominal muscle straining for at least four weeks after surgery and in someone who engages in powerlifting or bodybuilding it might be reasonable to consider an even longer break before returning to maximal effort lifting.

when patients are searching for a medical provider to assist them in achieving their health goals, several factors need to be considered, not least of which is whether the patient’s and provider’s goals and philosophy of care are aligned. The modern medical system talks a lot about patient noncompliance But often fails to take into account whether the directions and recommendations being given are in alignment with the patient’s world-view, capabilitie, and personal care goals. Ultimately, each patient is individually responsible for their own healthcare outcomes. Finding a care provider who will acknowledge that and help the patient achieve their stated goals leads to more individualized success. Patients should, of course, feel comfortable discussing their hobbies and lifestyle choices with their doctor, but if the doctor is not supportive of those choices then sometimes it might be necessary to search for another provider who is more educated about those topics and comfortable with them. For any weightlifters out there who are having a hard time finding a surgeon who will fix their hernia, plan a vacation to Bar Harbor, Maine and come see me.

If you are dealing with a hiatal hernia (and you’re not in a small rural community where all of your work up is likely to be done by a General Surgeon), your evaluation and care will likely be split between several providers. The evaluation will start with a referral from your primary care provider and the initial starting point will likely be GI (a.k.a. gastroenterology), who may recommend an EGD (fiber optic camera endoscopy of the esophagus and stomach and proximal small bowel), possibly with placement of a temporary probe in the lower esophagus to monitor pH levels for a couple days. Hiatal hernia is not the only cause of dysphasia to solids and an EGD helps to rule out things like scar tissue or stenosis in the esophagus, which can be treated with stretching the lower esophagus to improve swallowing and thus help a patient avoid surgery sometimes. Discoordinated smooth muscle contraction is also a problem in some instances and a test called manometry may also be warranted at the discretion of the doctor doing the evaluation. This is more commonly a concern in older patients or those with long-standing diabetes. The GI doc may give a patient recommendations, or advise that surgery is not a good option, but ultimately only the surgeon can tell a patient whether or not they are a good candidate for fundoplication, which is the preferred manner of fixing a hiatal hernia, typically in conjunction with tightening of the diaphragmatic crura. There are several types of fundoplication but by far the most common is a Nissan fundoplication, which can be done with minimally invasive techniques (laparoscopic or robotic) and patients are be on their feet almost immediately after surgery with very little functional downtime. Patients have every right to seek the opinion of additional providers if they are not comfortable with the advice and recommendations being given by a provider. In the end, the patient is the master of their own ship and needs to be the one directing the care decisions, with the advice and input of providers whom they trust.

If a patient is diagnosed with an umbilical, incisional, inguinal, or other hernia, none of the tests used with hiatal hernia are necessary and the primary care provider will refer patients directly to a General Surgeon for the repair. If the diagnosis was made on physical exam alone, some kind of imaging such as an ultrasound or a CT scan may be needed to further investigate the contents of the hernia, but that is not necessary in all cases. smoking cessation is strongly recommended for anyone considering a hernia repair, for myriad obvious general health reasons, but also specifically because chronic coughing is one of the most common causes of repair failure. For obese patients, weight loss is strongly recommended prior to hernia repair. Obesity causes increased problems with anesthesia and with healing from hernia repair. Incisional hernias (a hernia that occurs when an incision made for a different operative purpose does not heal well or tears back open during the postoperative course) are far more common in obese patients than in those of normal body weight, due to the constant tension on the abdominal wall caused by the obesity as well as impaired insulin sensitivity, which increases the risk of wound infections, another common cause of postoperative hernias. High protein intake in the perioperative period is very important to optimize wound healing and surgical recovery.

I hope you find this information useful. Nothing in the information provided above constitutes establishment of a patient/physician relationship and nothing above is intended as individualized care advice for a specific patient.

Lift heavy, live long.
Dr. Dougherty

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Hey thanks so much for getting back to my post. This info is so incredibly helpful and I so greatly appreciate it. You seriously have no idea.

I really appreciate you taking the time to get back to my post. Its incredibly helpful. Sorry if this is a repost fyi. I forgot to tag you in my intial reply lol.Currently my gi believes the cause of my hernia is from my crohns disease. In my latest endoscopy last week they found a bunch of ulcers in my duodenum which they believe created the hernia. Definitely not weight related as Ive always been very underweight due to the crohns lol. They still dont want to do surgery however because of my lifting. I guess my problem is more of getting a referral for surgery. Because I do have an excellent surgeon who has operated on me in the past for bowel resections ive had due to crohns. And he himself lifts. So he definitely gets the importance of it. After my last bowel resection with him he let me start lifitng again after 4 weeks and i felt great for a time. So I have no doubt he’d be ok with it. I guess really its just hard to get any of the gi’s ive seen including my main one to write a referral to him for the surgery because they themselves are quite old and do not support heavy lifting. I guess probably my next step will be perhaps calling him directly and asking if he could get me in without a referral somehow as he knows me. If that doesnt plan out who know I might just have to take that vacation to Bar Harbour Maine you were talking about lol. Regardless this post has been insanely helpful to me and I am extremely greatful. Hopefullly now ill be able to try and get this taken care of so I can get back to eating solids again. Thanks so much!

Edison

Edison: i’m glad you found the general hernia information helpful. I’m not aware of an association between Crohn’s disease and any mechanism that could create a hiatal hernia, unless you experience a lot of frequent very forceful vomiting. In most areas you would still be considered an active patient of your surgeon if any of the prior operations took place inside of the last three years. Outside of that window, it would be up to the surgeon whether they can see you without a referral. It’s usually the insurance companies that get in the way and hamstring providers from doing direct care without a referral. You can also get a referral from your primary care provider. it sounds like that may be more effective since your GI isn’t being cooperative. You should be aware that with your history of chronic inflammatory disease and multiple prior abdominal surgeries, you are bound to have widespread intraperitoneal adhesions. This can significantly impair the ability to do a fundoplication laparoscopically and if you were to have that surgery it might have to be an open approach, which is much more difficult to recover from than a laparoscopic surgery. That is definitely something that you would need to discuss with your surgeon in person. The biological medications and corticosteroids commonly used to treat Crohn’s disease also have a very significant impact on postoperative healing. Wound infections and incisional hernia rates are much higher in patients using those agents. Also, you likely will not find any surgeon willing to offer repair if the Crohn’s disease is not under very good control or even in durable remission.

Keep talking to your doctors and keep advocating for what you know you need.