- A hiatal hernia is the herniation of a portion of the stomach into the thoracic cavity through the diaphragmatic esophageal hiatus.
- Most patients with hiatal hernias are asymptomatic. Symptomatic
patients present similarly to patients with GERD.
● Chest pain
● Postprandial fullness
● GI bleed
● Wheezing with bowel sounds heard over the left lung base
1. Type I: Sliding, axial, or concentric hiatal hernia (most common type, 99%). The GE junction protrudes through the hiatus into the thoracic cavity
2. Type II: Paresophageal hernia (1%). The GE junction stays at the level of the diaphragm, but part of the stomach bulges into the thoracic cavity and stays there at all times, not being affected by swallowing
3. Type III: Mixed (rare), a combination of types I and II
4. Type IV: Large defect in hiatus that allows other intraabdominal organs to enter the hernia sac
● Hiatal hernias are thought to develop from an imbalance between normal pulling forces of the esophagus throughthe diaphragmatic hiatus during swallowing and the supporting
structures maintaining normal esophagogastric junction positioning in association with repetitive stretching that results in rupture of the phrenoesophageal membrane.
- Peptic ulcer disease
- Unstable angina (coronary syndrome)
- Esophagitis (e.g., Candida, herpes, NSAIDs, etc.)
- Esophageal spasm
- Barrett’s esophagus
- Schatzki’s ring
- Zenker’s diverticulum
- Esophageal cancer
- Barium contrast UGI series best defi nes the anatomic abnormality . A hiatal hernia is considered to be present if the gastric cardia is herniated 2 cm above the hiatus.
UGI may reveal a tortuous esophagus.
- Upper GI endoscopy is useful to document the presence of a hiatal hernia and also to exclude common associated fi ndings of esophagitis and Barrett’s esophagus. A hiatal hernia
- can be found incidentally and is diagnosed if 2 cm of
gastric rugal fold is seen above the margins of the diaphragmatic
- Lifestyle modifi cations with avoidance of foods and drugs that decrease lower esophageal pressure (e.g. caffeine, chocolate, mint, calcium channel blockers, and anticholinergics).Weight loss
- Avoid large quantities of food with meals
- Sleep with the head of the bed elevated 4 to 6 inches with blocks placed at base of the bed
- Antacids, H2 antagonists, PPIs may be useful to relieve symptoms.
- When indicated, surgery (laparoscopic or open) can be done in patients with refractory symptoms impairing quality of life and causing both intestinal (e.g., recurrent GI
bleeds) and extraintestinal complications (e.g., aspiration pneumonia, asthma, and ENT complications).
- Prophylactic surgery is a consideration in all patients with paresophageal hiatal hernias because they have a higher incidence of strangulation.