Signs and Symptoms of Hiatal Hernia
Hiatal hernias commonly present with heartburn and regurgitation (typical GERD symptoms), but can also manifest with dysphagia, chest pain, respiratory symptoms, and in severe cases, acute complications like gastric obstruction or strangulation.
Symptom Presentation by Hernia Type
Type I (Sliding Hiatal Hernia - 90% of cases)
Type I hernias primarily cause gastroesophageal reflux symptoms due to displacement of the gastroesophageal junction above the diaphragm 1:
- Heartburn - the most common symptom, approximately 70% sensitive and specific for objective GERD 2
- Regurgitation of liquids and food back into the mouth 3
- Non-cardiac chest pain 2
- Symptoms worsen after meals or during sleep due to mechanical factors 2
- Dysphagia (difficulty swallowing) 3, 4
Type II-IV (Paraesophageal and Mixed Hernias)
Paraesophageal hernias (Types II-IV) present with both gastrointestinal and respiratory symptoms, with higher risk of mechanical complications 2:
Gastrointestinal Symptoms:
- Dysphagia - more prominent than in Type I 4
- Epigastric pain and discomfort 3, 5
- Gastric obstruction 2
- Bleeding 2
Respiratory Symptoms:
- Dyspnea (shortness of breath) - particularly common, reported in 86% of traumatic diaphragmatic hernias 2
- Chest pain - can mimic cardiac pathology 5
- Respiratory distress that may be misdiagnosed as pneumonia or bronchiolitis 2
- 25-50% decrease in pulmonary function due to herniated contents compressing thoracic structures 2
Acute Complications (Surgical Emergency)
Severe symptoms requiring urgent evaluation include 2:
- Severe epigastric pain with retching - suggests hernia incarceration 4
- Gastric volvulus 2
- Bowel strangulation leading to perforation, peritonitis, and sepsis 2
- Multi-organ failure - carries high mortality 2
Clinical Presentation Patterns
Symptomatic vs. Asymptomatic
- Many hiatal hernias are asymptomatic and discovered incidentally on imaging or endoscopy 3, 6
- Asymptomatic hernias become symptomatic at approximately 1% per year 6
- Severe symptoms occur in 46% of congenital diaphragmatic hernias in adults 2
Delayed Presentation
Hiatal hernias can remain asymptomatic for decades before becoming symptomatic 2:
- Delayed diagnosis occurs in 5-45% of all congenital diaphragmatic hernias 2
- Nonspecific presentation frequently leads to misdiagnosis 2
- Symptoms worsen as the hernia enlarges or causes secondary visceral complications 2
Key Clinical Factors Suggesting Hiatal Hernia
Central obesity and/or known hiatal hernia point to a mechanical etiology of gastroesophageal reflux 2:
- Symptoms burden increases following meals 2
- Nocturnal symptoms are prominent 2
- Post-prandial symptoms suggest involvement of the acid pocket 2
Important Clinical Pitfalls
- Normal chest radiographs occur in 11-62% of diaphragmatic hernias, making clinical suspicion essential 2
- Chest pain from hiatal hernia can mimic coronary pathology, particularly in elderly patients with cardiac risk factors 5
- Right-sided hernias are more commonly missed (50% of delayed diagnoses) 2
- Initial radiographic findings are misinterpreted in approximately 25% of cases 2