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Hiatus Hernia

by Michael C. DiMarino, MD

Hiatus hernia is a protrusion of the stomach through the diaphragmatic hiatus. Most hernias are asymptomatic, but an increased incidence of acid reflux may lead to symptoms of gastroesophageal reflux disease (GERD). Diagnosis is by barium swallow. Treatment is directed at symptoms of GERD if present.

Etiology

Etiology is usually unknown, but a hiatus hernia is thought to be acquired through stretching of the fascial attachments between the esophagus and diaphragm at the hiatus (the opening through which the esophagus traverses the diaphragm).

Pathophysiology

In a sliding hiatus hernia (the most common type), the gastroesophageal junction and a portion of the stomach are above the diaphragm. In a paraesophageal hiatus hernia, the gastroesophageal junction is in the normal location, but a portion of the stomach is adjacent to the esophagus in the diaphragmatic hiatus. Hernias may also occur through other parts of the diaphragm (see Diaphragmatic Hernia).

Understanding Hiatus Hernia

A hiatus hernia is an abnormal bulging of a portion of the stomach through the diaphragm.

A sliding hiatus hernia is common and is an incidental finding on x-ray in > 40% of the population; therefore, the relationship of hernia to symptoms is unclear. Although most patients with GERD have some degree of hiatus hernia, < 50% of patients with hiatus hernia have GERD.

Symptoms and Signs

Most patients with a sliding hiatus hernia are asymptomatic, but chest pain and other reflux symptoms can occur. A paraesophageal hiatus hernia is generally asymptomatic but, unlike a sliding hiatus hernia, may incarcerate and strangulate. Occult or massive GI hemorrhage may occur with either type.

Diagnosis

  • Barium swallow

A large hiatus hernia is often discovered incidentally on chest x-ray. Smaller hernias are diagnosed with a barium swallow.

Treatment

  • Sometimes a proton pump inhibitor

An asymptomatic sliding hiatus hernia requires no specific therapy. Patients with accompanying GERD should be treated with a proton pump inhibitor. A paraesophageal hernia should be reduced surgically because of the risk of strangulation.

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