Hiatal Hernia : A hiatal hernia is present when a lax or defective
phrenoesophageal membrane allows protrusion of the stomach up through
the esophageal hiatus of the diaphragm.
The type of hiatal hernia is defined by the location of the GE junction
and the relationship of the stomach to the distal esophagus.
1. In type I or sliding hiatal hernia, the phrenoesophageal membrane
is intact but lax, thereby allowing the distal esophagus and gastric
cardia to herniated through the esophageal hiatus. The GE junction is
therefore located above the diaphragm. This is the most common type
and is usually asymptomatic.
2. A type II or paraesophageal hiatal hernia occurs when a focal
defect is present in the phrenoesophageal membrane, usually anterior
and lateral to the esophagus, which allows a protrusion of peritoneum
to herniated upward alongside the esophagus through the esophageal hiatus.
The GE junction remains anchored within the abdomen, whereas the greater
curvature of the stomach rolls up into the chest alongside the distal
esophagus. Eventually, most of the stomach can herniate. Because the
stomach is anchored at the pylorus and cardia, however, the body of
the stomach undergoes a 180-degree organoaxial rotation and ends up
as an upside-down, intrathoracic stomach when it is herniated.
3. Type III represents a combination of types I and II. This
type is more common than is a pure type II and is characterized by herniation
of the greater curvature of the stomach and the GE junction into the
4. A type IV hiatal hernia in which abdominal organs other than
or in addition to the stomach herniate through the hiatus. Typically,
these hernias are large and contain colon or spleen in addition to the
stomach within the chest.
Symptoms and complications in patients with sliding (type I) hiatal
hernias are related to associated GE reflux. Paraesophageal and combined
(types II, III and IV) hernias frequently produce postprandial pain
or bloating, early, satiety, breathlessness with meals and mild dysphagia
related to compression of the distal esophagus by the adjacent herniated
stomach. The herniated gastric pouch is susceptible to volvulus, obstruction
and infarction and can develop ischemic ulcers with frank or occult
Daignosis and Evaluation
1. Chest X-ray: The finding of an air-fluid level in the posterior
mediastinum on the lateral X-ray suggests the presence of a hiatal hernia.
Differential diagnosis includes mediastinal cyst, abscess, or a dilatated
2. A barium swallow confirms the diagnosis and defines any coexisting
esophageal abnormalities, including strictures or ulcers, and is the
diagnostic study of choice. The positions of the GE junction and proximal
stomach define the type of hiatal hernia.
3. Esophagogastroduodenoscopy (EGD) is indicated in patients
with symptoms of reflux or dysphagia to determine the degree of esophagitis,
presence of a stricture, Barretts esophagus or a coexisting abnormality.
EGD also establishes the location of the GE junction in relation to
the hiatus. A sliding hiatal hernia is present when 2 cm or more of
gastric mucosa is present between the diaphragmatic hiatus and the mucosal
4. Esophageal manometry to evaluate esophageal motility is warranted
in patients who are being considered for operative repair.
1. Asymptomatic sliding hernias require no treatment.
2. Patients with sliding hernias and GER with mild esophagitis should
undergo an initial trial of medical management.
3. Patients who fail to obtain symptomatic relief with medical therapy
or who have severe esophagitis should undergo esophageal testing to
determine their suitability for an antireflux procedure and hiatal hernia
4. Patients who do not experience reflux but have symptoms related to
their hernia (chest pain, intermittent dysphagia, or esophageal obstruction)
should undergo hiatal hernia repair.
5. All patients who are found to have a type II, III or IV hiatal hernia
and who are operative candidates should be considered for repair. Medically
treated patients with a paraesophageal hernia, even when asymptomatic
have nearly a 30% incidence of death from the development of a catastrophic
complication. Operative repair can be performed through either an abdominal
or thoracic approach and consists of reduction of the hernia, resection
of the sac, and closure of the hiatal defect. In combined (type III)
hernias, the esophagus frequently is shortened, and therefore a thoracic
approach is preferred.
6. Paraesophageal hiatal hernias are associated with a 60% incidence
of GER. Furthermore, the operative dissection may lead to postoperative
GER in previously asymptomatic patients. Therefore, an antireflux procedure
should be performed at the time of hiatal hernia repair.