Hiatal hernia

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Hiatal hernia
Other names: Hiatus hernia
A drawing of a hiatal hernia
SpecialtyGastroenterology, general surgery
SymptomsTaste of acid in the back of the mouth, heartburn, trouble swallowing[1]
ComplicationsIron deficiency anemia, volvulus, bowel obstruction[1]
TypesSliding, paraesophageal[1]
Risk factorsObesity, older age, major trauma[1]
Diagnostic methodEndoscopy, medical imaging, manometry[1]
TreatmentRaising the head of the bed, weight loss, medications, surgery[1]
MedicationH2 blockers, proton pump inhibitors[1]
Frequency10–80% (US)[1]

A hiatal hernia is a type of hernia in which abdominal organs (typically the stomach) slip through the diaphragm into the middle compartment of the chest.[1][2] This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn.[1][2] Other symptoms may include trouble swallowing and chest pains.[1] Complications may include iron deficiency anemia, volvulus, or bowel obstruction.[1]

The most common risk factors are obesity and older age.[1] Other risk factors include major trauma, scoliosis, and certain types of surgery.[1] There are two main types: sliding hernia, in which the body of the stomach moves up; and paraesophageal hernia, in which an abdominal organ moves beside the esophagus.[1] The diagnosis may be confirmed with endoscopy or medical imaging.[1] Endoscopy is typically only required when concerning symptoms are present, symptoms are resistant to treatment, or the person is over 50 years of age.[1]

Symptoms from a hiatal hernia may be improved by changes such as raising the head of the bed, weight loss, and adjusting eating habits.[1] Medications that reduce gastric acid such as H2 blockers or proton pump inhibitors may also help with the symptoms.[1] If the condition does not improve with medications, a surgery to carry out a laparoscopic fundoplication may be an option.[1]

Between 10% and 80% of people in the United States are affected.[1] Women are more commonly affected than men.[3] The condition becomes more common with age.[3] Hiatal hernias were first reported in 1853, and first diagnosed using x-rays in 1900.[4]

Signs and symptoms

Hiatal hernia has often been called the "great mimic" because its symptoms can resemble many disorders. Among them, a person with a hiatal hernia can experience dull pains in the chest, shortness of breath (caused by the hernia's effect on the diaphragm), heart palpitations (due to irritation of the vagus nerve), and swallowed food "balling up" and causing discomfort in the lower esophagus until it passes on to the stomach. In addition, hiatal hernias often result in heartburn but may also cause chest pain or pain with eating.[1]

In most cases however, a hiatal hernia does not cause any symptoms. The pain and discomfort that a patient experiences is due to the reflux of gastric acid. While there are several causes of acid reflux, it occurs more frequently in the presence of hiatal hernia.[5][6]

In newborns, the presence of Bochdalek hernia can be recognised[7] from symptoms such as difficulty breathing[8] fast respiration, increased heart rate.[9]


The following are potential causes of a hiatal hernia.[10] Increased pressure within the abdomen caused by:[10]

Obesity and older age are also general risk factors.[10]


The diagnosis of a hiatal hernia is typically made through an upper GI series, endoscopy or high resolution manometry.[11]


Schematic diagram of different types of hiatus hernia. Green is the esophagus, red is the stomach, purple is the diaphragm, blue is the HIS-angle. A is the normal anatomy, B is a pre-stage, C is a sliding hiatal hernia, and D is a paraesophageal (rolling) type.

Four types of esophageal hiatal hernia are identified:[13][14]

Type I: A type I hernia, also known as a sliding hiatal hernia, occurs when part of the stomach slides up through the hiatal opening in the diaphragm.[15] There is a widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal ligament, allowing a portion of the gastric cardia to herniate upward into the posterior mediastinum. The clinical significance of type I hernias is in their association with reflux disease. Sliding hernias are the most common type and account for 95% of all hiatal hernias.[16] (C)

Type II: A type II hernia, also known as a paraesophageal or rolling hernia, occurs when the fundus and greater curvature of the stomach roll up through the diaphragm, forming a pocket alongside the esophagus.[15] It results from a localized defect in the phrenoesophageal ligament while the gastroesophageal junction remains fixed to the pre aortic fascia and the median arcuate ligament[13]. The gastric fundus then serves as the leading point of herniation. Although type II hernias are associated with reflux disease, their primary clinical significance lies in the potential for mechanical complications[13]. (D)

Type III: Type III hernias have elements that indicates progressive enlargement of the hernia through the hiatus, the phrenoesophageal ligament stretches, displacing the gastroesophageal junction above the diaphragm[17][18]

Type IV: Type IV hiatus hernia is associated with a large defect in the phrenoesophageal ligament, allowing other organs, such as colon, spleen and small intestine to enter the hernia sac.[14] The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180° around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation the abnormality is usually referred to as an intrathoracic stomach.[19]


In the great majority of cases, people experience no significant discomfort, and no treatment is required. People with symptoms should elevate the head of their beds and avoid lying down directly after meals.[1] If the condition has been brought on by being overweight, weight loss may be indicated.[20]


In terms of medications for this condition, antisecretory drugs like proton pump inhibitors and H2 receptor blockers can be used to reduce acid secretion.[21]


There is tentative evidence from non controlled trials that oral neuromuscular training may improve symptoms.[22]


Surgery may be considered if reflux symptoms are not well controlled by medical therapy, if life long medication needs to be avoided, or there is presence of complications such as Barrett's esophagus, ulcer or stricture.[23][24] The operation is usually a fundoplication, also known as a Nissen fundoplication.[1][25][26] It involves wrapping the upper part of the stomach, the gastric fundus, around the lower part of the esophagus, preventing herniation of the stomach through the diaphragm, thereby reducing the reflux of gastric acid, and has been increasingly performed laparoscopically since the 1990s.[23][25] Complications are rare,[25] and include most commonly difficulty swallowing and bloating, which usually settle with time.[25] Haemorrhage, surgical hernias and infection can also occur.[25] Recovery is usually quick and long term results good.[23]


Incidence of hiatal hernias increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia.[27] Of these, 9% are symptomatic, depending on the competence of the lower esophageal sphincter (LES). 95% of these are "sliding" hiatal hernias, in which the LES protrudes above the diaphragm along with the stomach,[28] and only 5% are the paraesophageal, in which the LES remains stationary, but the stomach protrudes above the diaphragm.[29]

Hiatal hernias are most common in North America and Western Europe and rare in rural African communities.[30] Some have proposed that insufficient dietary fiber and the use of a high sitting position for defecation may increase the risk.[31]


Hiatal hernias were first reported in 1853 by Bowditch. Two years later, Rokitansky showed that inflammation of the esophagus was due to acid reflux, and in 1900 hiatal hernias were diagnosed by Hirsch using x-rays.[4]


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