(See also Overview of Esophageal and Swallowing Disorders Overview of Esophageal and Swallowing Disorders The swallowing apparatus consists of the pharynx, upper esophageal (cricopharyngeal) sphincter, the body of the esophagus, and the lower esophageal sphincter (LES). The upper third of the esophagus... read more .)
Etiology of Hiatus Hernia
Etiology of hiatus hernia 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 of Hiatus Hernia
There are 2 main types of hiatus hernia:
Sliding hiatus hernia (most common): Gastroesophageal junction and a portion of the stomach are above the diaphragm.
Paraesophageal hiatus hernia: 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 Diaphragmatic Hernia Diaphragmatic hernia is protrusion of abdominal contents into the thorax through a defect in the diaphragm. Lung compression may cause persistent pulmonary hypertension. Diagnosis is by chest... read more ).
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 gastroesophageal reflux disease (GERD) have some degree of hiatus hernia, < 50% of patients with hiatus hernia have GERD.
Symptoms and Signs of Hiatus Hernia
Most patients with a sliding hiatus hernia are asymptomatic, but chest pain and other reflux symptoms Symptoms and Signs Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia... read more can occur. A paraesophageal hiatus hernia is generally asymptomatic but, unlike a sliding hiatus hernia, may incarcerate and strangulate. Occult or massive gastrointestinal hemorrhage may occur rarely with either type.
Diagnosis of Hiatus Hernia
Sometimes upper endoscopy
A large hiatus hernia is often discovered incidentally on chest x-ray. Smaller hernias are diagnosed with a barium swallow.
Hernias can also be seen with upper endoscopy.
Treatment of Hiatus Hernia
Sometimes surgical repair
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.
For a paraesophageal hernia, repair should be considered because of the risk of strangulation.