Hiatal hernia



A hiatal hernia is a type of hernia in which abdominal organs, typically the stomach, slip through the diaphragm into the middle compartment of the chest.



This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn.


Frequency ranges from 10-80% of population.


Incidence of HHs increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia.

Other symptoms may include trouble swallowing and chest pains.


HH complications may include iron deficiency anemia, volvulus, or bowel obstruction.


Types of HH:


There are two main types: sliding hernia, in which the body of the stomach moves up; and paraesophageal hernia, in which an abdominal organ moves beside the esophagus.



Sliding, paraesophageal



Risk factors for HH: 



The most common risk factors are obesity and older age.



Other risk factors include major trauma, scoliosis, and certain types of surgery.



Diagnostic methods:



The diagnosis may be confirmed with endoscopy or medical imaging.



Endoscopy is typically only required when concerning symptoms are present, symptoms are resistant to treatment, or the person is over 50 years of age.





Raising the head of the bed, weight loss, medications, surgery



Symptoms from a HH  may be improved by changes such as raising the head of the bed, weight loss, and adjusting eating habits.



Medications that reduce gastric acid such as H2 blockers or proton pump inhibitors may also help with the symptoms.



Surgery with a laparoscopic fundoplication may be an option.


Its symptoms can resemble many disorders: chest, shortness of breath, caused by the hernia’s effect on the diaphragm, heart palpitations (due to irritation of the vagus nerve, and swallowed food causing discomfort in the lower esophagus until it passes on to the stomach. 


HHS often result in heartburn but may also cause chest pain or pain with eating.

In most cases however, a hiatal hernia does not cause any symptoms. 


The pain and discomfort that a patient experiences is due to the reflux of gastric acid, air, or bile. 


Potential causes of a hiatal hernia:


Increased pressure within the abdomen caused by:

Heavy lifting or bending over

Frequent or hard coughing

Hard sneezing

Violent vomitingStraining during defecation 

Obesity and age-related changes to the diaphragm.

Diagnosis of a hiatal hernia is typically made through an upper GI series, endoscopy, high resolution manometry, esophageal pH monitoring, and computed tomography (CT). 

Barium swallow as in upper GI series:  visualizes the size, location, stricture, stenosis of o esophagus, and can also evaluate the o esophageal movements. 


Endoscopy can analyze the esophageal surface for erosions, ulcers, and tumors. 


Manometry can determine the intergrity of eosophageal movements, and the presence of esophageal achalasia. 


pH testings allows for the analysis of acid reflux episodes. 


CT scan is useful in diagnosing complications of hiatal hernia such as gastric volvulus, perforation, pneumoperitoneum, and pneumomediastinum.

There are four types of esophageal hiatal hernia.


Type I: A type I hernia, also known as a sliding hiatal hernia, occurs when part of the stomach slides up through the hiatal opening in the diaphragm.

With a sliding HH there is a widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal ligament, allowing a portion of the gastric cardia to herniate upward into the posterior mediastinum. 

The clinical significance of type I hernias is in their association with reflux disease, and they are the most common type accounting for 95% of all HHs.

Type II: A type II hernia, also known as a paraesophageal or rolling hernia.

The hernia occurs when the fundus and greater curvature of the stomach roll up through the diaphragm, forming a pocket alongside the esophagus.

A paraesophageal  hernia results from a localized defect in the phrenoesophageal ligament while the gastroesophageal junction remains fixed to the pre aortic fascia and the median arcuate ligament. 

The gastric fundus is the leading point of herniation. 

Type II hernias are also associated with reflux disease, but their primary clinical significance is their potential for mechanical complications. 

Type III hernias have elements of both types I and II hernias. 

As progressive enlargement of the hernia occurs through the hiatus, the phrenoesophageal ligament stretches, displacing the gastroesophageal junction above the diaphragm, thereby adding a sliding element to the type II hernia.

Type IV hiatus hernia is associated with a large defect in the phrenoesophageal ligament, allowing other organs, such as colon, spleen, pancreas and small intestine to enter the hernia sac.

The most advanced stage of type I and type II hernias occurs when the whole stomach migrates up into the chest.

The stomach rotates 180° around its longitudinal axis, with the cardia and pylorus as fixed points:  an intrathoracic stomach.

The majority of cases of HH, patients  experience no significant discomfort, and no treatment is required. 

People with symptoms should elevate the head of their beds and avoid lying down directly after meals. If the condition has been brought on by stress, stress reduction techniques are advised

If overweight, weight loss is indicated.

Antisecretory drugs like proton pump inhibitors and H2 receptor blockers can be used to reduce acid secretion. 

Medications that reduce the lower esophageal sphincter (LES) pressure should be avoided.

When the hiatal hernia is unusually large, or is of the paraesophageal type, it may cause esophageal stricture or severe discomfort. 

About 5% of hiatal hernias are paraesophageal. 


If symptoms from such a HH  are severe, threatening  to injure the esophagus or is causing Barrett’s esophagus, surgery is sometimes recommended. 

Complications from surgical procedures to correct a hiatal hernia include:  gas bloat syndrome, dysphagia, dumping syndrome, excessive scarring, and rarely, achalasia.


Surgical procedures sometimes fail over time, requiring a second surgery


In the ((Nissen fundoplication)), the gastric fundus of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. 


The procedure is now commonly performed laparoscopically. 


Laparoscopic fundoplication has relatively low complication rates, quick recovery, and relatively good long term results.


9% of HHS are symptomatic, depending on the competence of the lower esophageal sphincter (LES). 


95% of HHS  are sliding hiatal hernias, in which the LES protrudes above the diaphragm along with the stomach, and only 5%  are paraesophageal in which the LES remains stationary, but the stomach protrudes above the diaphragm.


Hiatal hernias are most common in North America and Western Europe and rare in rural African communities.



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