Practice Essentials

A hiatal hernia occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus.
Most hiatal hernias are asymptomatic and are discovered incidentally, but rarely, a life-threatening complication
may present acutely. The image below depicts a paraesophageal hiatal hernia.

A paraesophageal hernia is seen on an upper

gastrointestinal series. Note that the gastroesophageal junction remains below the diaphragm. Courtesy of David Y.
Graham, MD.

Signs and symptoms

Most people with hiatal hernias are asymptomatic. In a minority of individuals, hiatal hernias may predispose to
reflux or worsen existing reflux.
Complications of hiatal hernia may include the following:

Intermittent bleeding from associated esophagitis, erosions (Cameron ulcers), or a discrete esophageal ulcer,
leading to iron-deficiency anemia
Incarcerated hiatal hernia (rare; observed only with paraesophageal hernia)
The physical examination usually is unhelpful. Certain conditions may predispose to the development of hiatal
hernia, including the following:

Muscle weakening and loss of elasticity with age

Pregnancy
Obesity
Abdominal ascites
Diaphragmatic hernias may be congenital or acquired. Acquired hiatal hernias are divided further into
nontraumatic (more common) and traumatic hernias. Nontraumatically acquired hernias are divided yet further
into 2 types: (1) sliding hiatal hernia and (2) paraesophageal hiatal hernia (a mixed variety is also possible).
See Presentation for more detail.

Diagnosis

The typical reason for evaluation is the presence of symptoms of gastroesophageal reflux disease (GERD) or a
chest radiograph suggesting a paraesophageal hernia.
A barium upper gastrointestinal series may yield the following findings:

Outpouching of barium at the lower end of the esophagus

A wide hiatus through which gastric folds are seen in continuum with those in the stomach
Occasionally, free reflux of barium
A barium study also helps distinguish a sliding from a paraesophageal hernia.
Upper GI endoscopy may be performed for the following purposes:

To diagnose hiatal hernia (though this is actually incidental)

To diagnose complications such as erosive esophagitis, ulcers in the hiatal hernia, Barrett esophagus, or
tumor
To permit biopsy of any abnormal or suspicious area
See Workup for more detail.

Management
When symptoms are due to GERD, treatment goals include the following:

Prevention of reflux of gastric contents

Improved esophageal clearance
Reduction in acid production
In the majority of patients, these goals are achieved by means of a combination of the following:

Modifying lifestyle factors

Neutralizing acid or inhibiting acid-producing mechanisms
Enhancing esophageal and gastric motility
If iron-deficiency anemia occurs, it usually responds well to proton-pump inhibitor (PPI) therapy.
Surgical treatment involves removing the hernia sac and closing the abnormally wide esophageal hiatus. It is
necessary only in the very few patients who have complications of GERD despite aggressive PPI treatment.
Potential surgical candidates include the following:

Young patients with severe or recurrent complications of GERD (eg, strictures, ulcers, or bleeding) who
cannot afford lifelong PPI treatment or prefer to avoid long-term pharmacotherapy
Patients with pulmonary complications (eg, asthma, recurrent aspiration pneumonia, chronic cough, or
hoarseness linked to reflux disease)
The 3 major types of surgical procedures that may be considered are as follows:

Nissen fundoplication (or a variant, the Toupet procedure)

Belsey fundoplication
Hill repair
See Treatment and Medication for more detail.

Background
A hiatal hernia occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus.
Although the existence of hiatal hernia has been described in earlier medical literature, it has come under
scrutiny only in the last century or so because of its association with gastroesophageal reflux disease (GERD)
and its complications. There is also an association between obesity and the presence of hiatal hernia. By far,
most hiatal hernias are asymptomatic and are discovered incidentally. On rare occasion, a life-threatening
complication, such as gastric volvulus or strangulation, may present acutely.

Pathophysiology
The esophagus passes through the diaphragmatic hiatus in the crural part of the diaphragm to reach the
stomach. The diaphragmatic hiatus itself is approximately 2 cm in length and chiefly consists of

musculotendinous slips of the right and left diaphragmatic crura arising from either side of the spine and
passing around the esophagus before inserting into the central tendon of the diaphragm. The size of the hiatus
is not fixed, but narrows whenever intra-abdominal pressure rises, such as when lifting weights or coughing.[1]
The lower esophageal sphincter (LES) is an area of smooth muscle approximately 2.5-4.5 cm in length. The
upper part of the sphincter normally lies within the diaphragmatic hiatus, while the lower section normally is
intra-abdominal. At this level, the visceral peritoneum and the phrenoesophageal ligament cover the
esophagus. The phrenoesophageal ligament is a fibrous layer of connective tissue arising from the crura, and it
maintains the LES within the abdominal cavity. The A-ring is an indentation sometimes seen on barium studies,
and it marks the upper part of the LES. Just below this is a slightly dilated part of the esophagus, forming the
vestibule. A second ring, the B-ring, may be seen just distal to the vestibule, and it approximates the Z-line or
squamocolumnar junction. The presence of a B-ring confirms the diagnosis of a hiatal hernia. Occasionally, the
B-ring also is called the Schatzki ring.
Any sudden increase in intra-abdominal pressure also acts on the portion of the LES below the diaphragm to
increase the sphincter pressure. An acute angle, the angle of His, is formed between the cardia of the stomach
and the distal esophagus and functions as a flap at the gastroesophageal junction and helps prevent reflux of
gastric contents into the esophagus (see the image below).

Hiatal hernia. Figure 1 shows the normal

relationship of the gastroesophageal junction, stomach, esophagus, and diaphragm. Figure 2 shows a sliding hiatal hernia
where the stomach immediately below the gastroesophageal junction is seen to prolapse through the diaphragmatic hiatus
into the chest. Figure 3 shows a paraesophageal hernia in which the cardia or fundus of the stomach prolapses through the
diaphragmatic hiatus, leaving the gastroesophageal junction within the esophageal cavity.

The gastroesophageal junction acts as a barrier to prevent reflux of contents from the stomach into the
esophagus by a combination of mechanisms forming the antireflux barrier. The components of this barrier
include the diaphragmatic crura, the LES baseline pressure and intra-abdominal segment, and the angle of His.
The presence of a hiatal hernia compromises this reflux barrier not only in terms of reduced LES pressure but
also reduced esophageal acid clearance. Patients with hiatal hernias also have longer transient LES relaxation
episodes particularly at night time. These factors increase the esophageal mucosa acid contact time
predisposing to esophagitis and related complications.

Frequency
United States
Hiatal hernias are more common in Western countries. The frequency of hiatus hernia increases with age, from
10% in patients younger than 40 years to 70% in patients older than 70 years.

International
Burkitt et al suggest that the Western, fiber-depleted diet leads to a state of chronic constipation and straining
during bowel movement, which could explain the higher incidence of this condition in Western countries. [2]

Mortality/Morbidity
Paraesophageal hernias generally tend to enlarge with time, and sometimes the entire stomach is found within
the chest. The risk of these hernias becoming incarcerated, leading to strangulation or perforation, is
approximately 5%. This complication is potentially lethal, and surgical intervention is necessary. Because of the
high mortality associated with this condition, elective repair often is advised wherever a paraesophageal hernia
is found.[3, 4]

Sihvo et al examined the mortality associated with adult paraesophageal hernia in a Finnish retrospective,
population-based study.[3] Five hundred sixty-three patients received surgical intervention and 67 received
conservative treatment for paraesophageal hernia. Death occurred in 32 patients, of whom 29 had concomitant
diseases.
Of the 563 patients in the surgical group, the overall mortality was 2.7% (15 patients), of whom 3 died following
elective repair.[3] Of the 67 patients in the conservative treatment group, 16.4% (11 patients) died; 13% (4
patients) of the deaths might have been avoided with elective surgical intervention. Of the 32 patients who died,
over half had type III (16 patients; 50%) or type IV (9 patients; 28.1%) had hiatal hernias; 4 patients (12.5%)
had had type II hiatal hernias, with the remaining 3 deceased having an unknown type. The causes of death
were primarily from incarceration (24 patients; 75%), followed by surgical complications (6 patients; 18.8%) and
bleeding ulcer (2 patients; 6.2%).[3]
Sihvo et al recommended of the paraesophageal hernia, at least in symptomatic patients, except for those at
high surgical risk.[3]
In a Swiss study, Larusson et al investigated the predictive factors for postoperative morbidity and mortality in
patients undergoing laparoscopic hernia repair.[4] Of 354 laparoscopic paraesophageal hernia repairs, age at 70
years or older was significantly associated with postoperative morbidity (24.4%) and mortality (2.4%) relative to
those younger than 70 years (10.1% postoperative morbidity, P = 0.001; 0% mortality, P = 0.045). Similar age
findings were noted with gastropexy but not with fundoplication.[4] In addition, high-risk patients had significantly
higher morbidity but not mortality.
Larusson et al concluded that age, American Society of Anesthesiologists (ASA) score, and type of operation
are significant predictive factors in patients undergoing laparoscopic paraesophageal hernia repair. [4] The
investigators advised caution in balancing surgical indications with each patient's comorbidities, age,
symptoms, and potentially life-threatening complications.[4]
Cardiac complications such as cardiac tamponade have been reported to occur following laparascopic Nissen
repair of large hiatal hernia.[5]

Sex
Hiatal hernias are more common in women than in men. This might relate to the intra-abdominal forces exerted
in pregnancy.

Age
Muscle weakening and loss of elasticity as people age is thought to predispose to hiatus hernia, based on the
increasing prevalence in older people. With decreasing tissue elasticity, the gastric cardia may not return to its
normal position below the diaphragmatic hiatus following a normal swallow. Loss of muscle tone around the
diaphragmatic opening also may make it more patulous

History
Hiatal hernias are relatively common and, in themselves, do not cause symptoms. For this reason, most people
with hiatal hernias are asymptomatic. Hiatal hernias may predispose to reflux or worsen existing reflux in a
minority of individuals. Physicians should resist the temptation to label hiatal hernia as a disease.
Patients can have reflux without a demonstrable hiatal hernia. When a hernia is present in a patient with
symptomatic GERD, the hernia may worsen symptoms for several reasons, including the hiatal hernia acting as
a fluid trap for gastric reflux and increasing the acid contact time in the esophagus. In addition, with a hiatal
hernia, episodes of transient relaxation of the LES are more frequent and the length of the high-pressure zone
is reduced. The main symptoms of a sliding hiatal hernia are those associated with reflux and its complications.
No clear correlation exists between the size of a hiatal hernia and the severity of the symptoms. A very large
hiatal hernia may be present with no symptoms at all. Some complications are specific for a hiatal hernia.

o
o

Esophageal complications
By far, the majority of hiatal hernias are asymptomatic.
Often, patients are left with the impression that they have a disease when a hiatal hernia is diagnosed.

In rare cases, however, a hiatal hernia may be responsible for intermittent bleeding from associated
esophagitis, erosions (Cameron ulcers), or a discrete esophageal ulcer, leading to iron-deficiency anemia.
The prevalence of large hiatal hernias in patients with iron deficiency anemia is 6-7%. This particular
complication is more likely in patients who are bed-bound or those who take nonsteroidal anti-inflammatory
drugs. Massive bleeding is rare.
Nonesophageal complications
o Incarceration of a hiatal hernia is rare and is observed only with paraesophageal hernia.
o When this occurs, it can present abruptly, with a sudden onset of vomiting and pain, sometimes requiring
immediate operative intervention.

Physical
The physical examination usually is unhelpful. Certain conditions predispose to the development of hiatus
hernia. These include obesity, pregnancy, and ascites.

Causes
See the list below:

o
o
o
o
o

Predisposing factors include the following:

Muscle weakening and loss of elasticity as people age is thought to predispose to hiatus hernia, based on
the increasing prevalence in older people. With decreasing tissue elasticity, the gastric cardia may not
return to its normal position below the diaphragmatic hiatus following a normal swallow. Loss of muscle
tone around the diaphragmatic opening also may make it more patulous.
Hiatal hernias are more common in women. This may relate to the intra-abdominal forces exerted in
pregnancy.
Burkitt et al suggest that the Western, fiber-depleted diet leads to a state of chronic constipation and
straining during bowel movement, which might explain the higher incidence of this condition in Western
countries.
Obesity predisposes to hiatus hernia because of increased abdominal pressure.
Conditions such as chronic esophagitis may cause shortening of the esophagus by causing fibrosis of the
longitudinal muscles and, therefore, predispose to hiatal hernia. However, which comes first, the hiatal
hernia worsening the reflux or the reflux-induced shortening of the esophagus, remains unknown.
The presence of abdominal ascites also is associated with hiatal hernias.
Diaphragmatic hernias may be congenital or acquired. Acquired hiatal hernias are divided further into
nontraumatic and traumatic hernias. The most common types of hernias are those acquired in a nontraumatic
fashion. Hernias acquired in a nontraumatic fashion are divided into 2 types, (1) sliding hiatal hernia and (2)
paraesophageal hiatal hernia. A mixed variety with coexisting sliding and paraesophageal components is
possible.
Sliding hiatal hernia by far is the most common type of hiatal hernia. It occurs when the gastroesophageal
junction, along with a portion of the stomach, migrates into the mediastinum through the esophageal hiatus
(see the image below). The majority of patients with demonstrated hiatal hernias are asymptomatic. This
type of hernia interferes with the reflux barrier mechanism in several ways. As the LES moves into the
chest, it no longer is exposed to positive intra-abdominal pressure and, therefore, is less effective as a
sphincter. In fact, the sphincter moves into an area of low pressure, which interferes with the sphincter
activity. In addition, the widening hiatus affects the competence of the diaphragmatic crura. The angle of
His is lost, making regurgitation of gastric contents more likely. These changes not only predispose to reflux
of gastric contents into the esophagus, but also prolong the acid contact time with the epithelium of the
esophagus.

Hiatal hernia. Figure 1 shows the normal

relationship of the gastroesophageal junction, stomach, esophagus, and diaphragm. Figure 2 shows a sliding hiatal
hernia where the stomach immediately below the gastroesophageal junction is seen to prolapse through the
diaphragmatic hiatus into the chest. Figure 3 shows a paraesophageal hernia in which the cardia or fundus of the
stomach prolapses through the diaphragmatic hiatus, leaving the gastroesophageal junction within the esophageal
cavity.

In paraesophageal hernia, also called rolling-type hiatal hernia, the widened hiatus permits the fundus of
the stomach to protrude into the chest, anterior and lateral to the body of the esophagus; however, the
gastroesophageal junction remains below the diaphragm (see Figure 3 of the image above). This causes
the stomach to rotate in a counter-clockwise direction. As the hiatus widens, increasing amounts of the
greater curvature of the stomach and, sometimes, the gastric-colic omentum, follow. The fundus eventually
comes to lie above the gastroesophageal junction, with the pylorus being pulled towards the diaphragmatic
hiatus. In this type of hernia, the anatomic relation of the stomach to the lower end of the esophagus (angle
of His) tends to remain unchanged, so gross acid reflux does not occur.

Laboratory Studies
The typical reasons for evaluation are symptoms of GERD or a chest radiograph suggesting a paraesophageal
hernia.

Imaging Studies
Barium upper gastrointestinal series
Although a chest radiograph may reveal a large hiatal hernia (see the first image below), and many incidentally
diagnosed hiatal hernias are discovered in this manner, a barium study of the esophagus helps establish the
diagnosis with greater accuracy (see the second image below).

Anteroposterior (left and lateral views (right) on

a chest radiograph showing a large hiatal hernia. Courtesy of David Y. Graham, MD.

Barium study shows a sliding hiatal hernia: The

gastric folds can be seen extending above the diaphragm. Courtesy of David Y. Graham, MD.

Typical findings include an outpouching of barium at the lower end of the esophagus, a wide hiatus through
which gastric folds are seen in continuum with those in the stomach, and, occasionally, free reflux of barium.
A barium study helps distinguish a sliding from a paraesophageal hernia (see the images below).

A paraesophageal hernia is seen on an upper

gastrointestinal series. Note that the gastroesophageal junction remains below the diaphragm. Courtesy of David Y.
Graham, MD.

Paraesophageal hernia is seen on barium upper

gastrointestinal series. The mucosal folds are seen going up into the chest, next to the esophagus. Courtesy of David Y.
Graham, MD.

Barium radiograph view of a large paraesophageal hernia.

Courtesy of David Y. Graham, MD.

In rare cases, the entire stomach may herniate into the chest (see the image below).

A large paraesophageal hernia in which the entire stomach is seen in

the chest cavity. Courtesy of David Y. Graham, MD.

The stomach may then undergo volvulus (see the image below) and subsequent incarceration and
strangulation.

Barium studies show gastric volvulus as the

herniated stomach undergoes rotation. This situation requires surgical intervention. Courtesy of David Y. Graham, MD.

Procedures
Endoscopy
Hiatal hernia is diagnosed easily using upper gastrointestinal endoscopy.
The diagnosis of a hiatal hernia actually is incidental, and endoscopy is used to diagnose complications such
as erosive esophagitis, ulcers in the hiatal hernia, Barrett esophagus, or tumor.
A hiatal hernia is confirmed when the endoscope is about to enter the stomach or on retrograde view once
inside the stomach (see the image below). If any doubt remains, the patient may be asked to sniff through the
nose, which causes the diaphragmatic crura to approximate, seen as a pinch, closing the lumen.

A retrograde view of a hiatal hernia seen at

endoscopy shows the gastric folds to the left of the scope shaft extending up into the hernia. Courtesy of David Y. Graham,
MD.

Endoscopy also permits biopsy of any abnormal or suspicious area.

Esophageal manometry
Traditionally, esophageal manometry has had a low sensitivity for diagnosing hiatal hernia, as compared to
endoscopy, and was therefore not appropriate in helping to establish a diagnosis.[6]
More recent studies with esophageal high-resolution manometry (HRM) appear to be more accurate for
detecting hiatal hernias. In one study that evaluated the HRM recordings, endoscopy reports, and barium
esophagograms of 90 patients, HRM had a 92% sensitivity and 95% specificity for identifying hiatal hernias
compared with a 73% sensitivity each for endoscopy and radiography.[7