A hiatal hernia occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus. Most hiatal hernias are asymptomatic and are discovered incidentally, but rarely, a life-threatening complication may present acutely. The image below depicts a paraesophageal hiatal hernia.
Hiatal hernia. A paraesophageal hernia is seen on an upper gastrointestinal radiograph series. Note that the gastroesophageal (GE) junction remains below the diaphragm. Courtesy of David Y Graham, MD.
Signs and symptoms
Most people with hiatal hernias are asymptomatic. In a minority of individuals, hiatal hernias may predispose to reflux or worsen existing reflux.
Complications of hiatal hernia may include the following:
Intermittent bleeding from associated esophagitis, erosions (Cameron ulcers), or a discrete esophageal ulcer, leading to iron-deficiency anemia
Incarcerated hiatal hernia (rare; observed only with paraesophageal hernia)
The physical examination usually is unhelpful. Certain conditions may predispose to the development of hiatal hernia, including the following:
Muscle weakening and loss of elasticity with age
Diaphragmatic hernias may be congenital or acquired. Acquired hiatal hernias are divided further into nontraumatic (more common) and traumatic hernias. Nontraumatically acquired hernias are divided yet further into 2 types: (1) sliding hiatal hernia and (2) paraesophageal hiatal hernia (a mixed variety is also possible).
See Presentation for more detail.
The typical reason for evaluation is the presence of symptoms of gastroesophageal reflux disease (GERD) or a chest radiograph suggesting a paraesophageal hernia.
A barium upper gastrointestinal series may yield the following findings:
Outpouching of barium at the lower end of the esophagus
A wide hiatus through which gastric folds are seen in continuum with those in the stomach
Occasionally, free reflux of barium
A barium study also helps distinguish a sliding from a paraesophageal hernia.
Upper GI endoscopy may be performed for the following purposes:
To diagnose hiatal hernia (though this is actually incidental)
To diagnose complications such as erosive esophagitis, ulcers in the hiatal hernia, Barrett esophagus, or tumor
To permit biopsy of any abnormal or suspicious area
See Workup for more detail.
When symptoms are due to GERD, treatment goals include the following:
Prevention of reflux of gastric contents
Improved esophageal clearance
Reduction in acid production
In the majority of patients, these goals are achieved by means of a combination of the following:
Modifying lifestyle factors
Neutralizing acid or inhibiting acid-producing mechanisms
Enhancing esophageal and gastric motility
If iron-deficiency anemia occurs, it usually responds well to proton-pump inhibitor (PPI) therapy.
Surgical treatment involves removing the hernia sac and closing the abnormally wide esophageal hiatus. It is necessary only in the very few patients who have complications of GERD despite aggressive PPI treatment. Potential surgical candidates include the following:
Young patients with severe or recurrent complications of GERD (eg, strictures, ulcers, or bleeding) who cannot afford lifelong PPI treatment or prefer to avoid long-term pharmacotherapy
Patients with pulmonary complications (eg, asthma, recurrent aspiration pneumonia, chronic cough, or hoarseness linked to reflux disease)
The 3 major types of surgical procedures that may be considered are as follows:
Nissen fundoplication (or a variant, the Toupet procedure)