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. Diagnosis is by barium swallow. Treatment is directed at symptoms of gastroesophageal reflux disease if present.
(See also Overview of Esophageal and Swallowing Disorders.)
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).
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 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
- Barium swallow
- 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.