Hiatal hernia
Summary
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A hiatal (or hiatus) hernia is the abnormal protrusion of an abdominal structure into
the thoracic cavity through a lax esophageal hiatus. Sliding hiatal hernias (type I), in
which the gastroesophageal junction (GEJ) and the gastric cardia migrate into the
thorax, account for 95% of hiatal hernias. In paraesophageal hernia (type II), only
the gastric fundus herniates into the thorax, and in mixed hiatal hernias (type III),
the GEJ and the gastric fundus herniate. Complex hiatal hernias (type IV) are rare and
characterized by herniation of the stomach and other abdominal organs. Most patients
with sliding hiatal hernias are asymptomatic and do not require medical or surgical
intervention. Patients experiencing symptoms of gastroesophageal reflux
disease (GERD) due to a sliding hiatal hernia can be treated with proton pump
inhibitors or antireflux surgery and/or managed with lifestyle changes. Patients
with paraesophageal hernia or mixed hiatal hernia may present with
intermittent dysphagia, substernal discomfort, and/or abdominal pain, and, in rare
cases, acute gastric volvulus and strangulation. Surgical intervention is necessary for
symptomatic patients with paraesophageal, mixed, or complex hiatal hernias to
prevent life-threatening complications.
For other diaphragmatic hernias, see “Congenital diaphragmatic hernias” and
“Acquired diaphragmatic hernias.”
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Definitions
Protrusion of any abdominal structure/organ into the thorax through a lax
diaphragmatic esophageal hiatus. In 95% of cases, a portion of the stomach is
herniated.
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Epidemiology
• Incidence increases with:
o Age: affects ∼ 70% of people > 70 years
o ↑ BMI
Epidemiological data refers to the US, unless otherwise specified.
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Etiology
The etiology is multifactorial.
• Lax diaphragmatic esophageal hiatus
o Advanced age
o Smoking
o Obesity
o Genetic predisposition (rare) [1]
• Prolonged periods of increased intra-abdominal pressure
o Pregnancy
o Ascites
o Chronic cough
o Chronic constipation
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Classification
Type I: sliding hiatal hernia [1]
• Most common type (95% of cases) [1]
• The GEJ and the gastric cardia slide up into the posterior
mediastinum.
• The gastric fundus remains below the diaphragm (hourglass stomach)
Type II: paraesophageal hiatal hernia [1]
• Part of the gastric fundus herniates into the thorax.
• The GEJ remains in its anatomical position below the diaphragm.
Type III: mixed hiatal hernia [1]
• Mix of types I and II
• The GEJ and a portion of the gastric fundus prolapse through the
hiatus.
Type IV: complex hiatal hernia [1]
• Herniation of any abdominal structure in addition to
the stomach (e.g., spleen, colon)
• Rarest type
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Pathophysiology
Anatomy
• Esophageal hiatus
o Central opening of the diaphragm, which allows
the esophagus to pass through into the peritoneal cavity;
forms the lower part of the esophageal sphincter and the
reflux barrier
o Formed by:
▪ Left and right paravertebral tendinous crura
▪ Median arcuate ligament
• Gastroesophageal junction (GEJ)
o Normally lies at the level of the esophageal hiatus
o Phrenoesophageal ligament (PEL) attaches to
the esophagus at the GEJ
▪ Peritoneal fold that encircles the distal portion
of the esophagus and gastroesophageal
junction and connects them to
the peritoneal surface of the diaphragm
▪ Closes the esophageal hiatus and helps
maintain the intra-abdominal position of the GEJ
Changes in the presence of a hiatal hernia
• Predisposing factors lead to laxity of the esophageal hiatus, e.g.:
o Advanced age → phrenoesophageal ligament weakens
o Smoking → loss of elastin fibres in the diaphragmatic crura
oObesity → deposition of fat in and around the crura →
widened hiatus
• Relative negative intrathoracic pressure and the lax
hiatus → herniation of the abdominal contents into the thorax → loss of
reflux barrier + compromised fluid emptying
of distal esophagus → gastroesophageal reflux disease (GERD)
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Clinical features
• Type I hiatal hernia [2]
o Most patients are asymptomatic.
o Symptoms of GERD may be present.
• Type II hiatal hernia and type IV hiatal hernia [2]
o Epigastric and/or substernal pain
o Early satiety, nausea, vomiting
o Postprandial dyspnea
o Retching
o Symptoms of GERD may be present.
• Type III hiatal hernia: combination of symptoms of other types
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Diagnosis
Hiatal hernias are often discovered incidentally on chest or abdomen imaging,
especially when asymptomatic.
Approach [1][3]
• Only obtain confirmatory studies (e.g., barium
swallow, upper endoscopy) if results are expected to alter treatment.
• Obtain urgent imaging (CT chest and abdomen) if acute complications
(e.g., gastric outlet obstruction) are suspected. [4]
• For patients with symptoms of GERD, obtain GERD diagnostics.
• Consider additional studies as required for preoperative assessment,
e.g., determining the extent of herniation.
Confirmatory studies [1][3][5]
• Barium swallow
o Most sensitive study for hiatal hernia [6]
o Used to evaluate hiatal hernia size and type
• Endoscopy
o Used to evaluate hiatal hernia size and type and to assess
for complications (e.g., Barrett esophagus) by
evaluating mucosal condition
o The location of the GEJ is determined using the Z-
line (squamocolumnar junction).
▪ Sliding hiatal hernia: Z-line lies > 2 cm above the
diaphragmatic hiatus [3]
▪ Paraesophageal hernia: Z-line remains
undisplaced and the gastric fundus herniates
through the hiatus
Imaging [1][5]
• Chest x-ray
o Not usually indicated for evaluation of hiatal hernias [3]
o Typical incidental findings
▪ Types I, II, III: retrocardiac soft tissue opacity
with or without air-fluid levels
▪ Type IV: retrocardiac visceral gas (small
bowel and/or colon) or soft tissue shadows
(spleen or omentum)
• CT thorax: Used for urgent preoperative evaluation of
paraesophageal hernias
o Can help determine the type, size, and contents of the hernia
o Can help detect acute complications (e.g., gastric
perforation, gastric volvulus)
Additional diagnostics [1][5]
• Esophageal manometry
o Helps calculate the size of a sliding hiatal hernia by
identifying the level of the diaphragmatic hiatus
o Can assess for esophageal motility
disorders (e.g., achalasia) preoperatively
• Esophageal pH monitoring
o Not diagnostic for hiatal hernias
o Can determine the extent of gastroesophageal reflux
Obtain diagnostics for GERD in patients with sliding hiatal hernias before
considering surgical treatment. [1]
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Treatment
Type I hiatal hernia [1][7]
Approach
• Asymptomatic patients: no treatment necessary
• Symptomatic patients
o Begin conservative management.
o Consider antireflux surgery in all patients with symptoms of
GERD, especially for:
▪ Failure or intolerance of conservative
management
▪ Large hiatal hernia
▪ Complications of GERD (e.g., bleeding,
strictures, ulcerations)
Conservative management
• Lifestyle modifications, e.g., avoidance of triggers such as nicotine
• Proton pump inhibitors
• See “Management of GERD” for details.
• See “Antacids and acid suppression medications” for PPI dosages.
Surgical techniques [3][2]
• Fundoplication, typically laparoscopic
• Hiatoplasty: reinforcement of the esophageal hiatus using sutures
and/or mesh
Surgical repair of asymptomatic type I hiatal hernias is not recommended. [1]
All other types [1][3][2]
The following applies to type II hiatal hernia, type III hiatal hernia, and type IV hiatal
hernia.
• Asymptomatic patients
o Usually managed conservatively with watchful waiting until
symptoms develop [3]
o Select patients may benefit from surgery.
• Symptomatic patients: surgery indicated [8]
o There is no standardized technique for paraesophageal
hernia repair.
o Techniques include: [7]
▪ Hernia reduction and hernia sac excision
▪ Closure of the hernia with hiatoplasty
▪ Gastropexy/fundopexy: fixation of the gastric
fundus to the diaphragm
▪ Fundoplication
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Complications
Type I hiatal hernia
• Arise from long-standing gastroesophageal reflux
• See "Complication of GERD.”
All other types
Strangulation and incarceration of herniated stomach and/or other intraabdominal
organs can result in ischemic complications requiring emergent surgical intervention.
• Upper gastrointestinal bleeding (occult/massive) → iron deficiency
anemia [9]
• Gastric ulcers
• Gastric perforation
• Gastric volvulus [1]
o A rare condition characterized by abnormal rotation of
the stomach
o Can occur in the abdomen or chest (upside-down
stomach)
o Classified according to the rotational axis: organoaxial (around
the long axis of the stomach) and mesenteroaxial (between the
lesser and greater curvature)
• Total gastric outlet obstruction
The complications of type II hiatal hernia, type III hiatal hernia, and type IV
hiatal hernia are often surgical emergencies.
We list the most important complications. The selection is not exhaustive.
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Tips and links Sources
last updated 05/02/2024
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