What are the symptoms of a hiatal hernia?

Symptoms of Hiatal Hernia

Heartburn and regurgitation are the hallmark symptoms of hiatal hernia, occurring in approximately 70% of patients with objective GERD, while paraesophageal hernias commonly present with dyspnea (86% of cases) and symptoms that worsen after meals or during sleep. 1, 2

Typical Esophageal Symptoms

• Heartburn is the most common symptom, with approximately 70% sensitivity and specificity for objective GERD in patients with hiatal hernia 2, 1
• Regurgitation of liquids and food back into the mouth occurs frequently, particularly at night 2, 3
• Non-cardiac chest pain is a common presenting symptom, especially in Type I (sliding) hernias 1
• Dysphagia (difficulty swallowing) can occur as the hernia progresses 3, 4
• Epigastric discomfort and pain in the stomach or esophageal region are frequently reported 3, 5

Respiratory and Thoracic Symptoms

• Dyspnea (shortness of breath) is particularly common in paraesophageal hernias, occurring in 86% of traumatic diaphragmatic hernias 1
• Chest pain and respiratory distress can mimic pneumonia or bronchiolitis, leading to misdiagnosis 1
• 25-50% decrease in pulmonary function can occur when herniated contents compress thoracic structures 1

Symptom Timing and Aggravating Factors

• Post-prandial worsening: Symptoms characteristically worsen after meals due to mechanical factors and involvement of the acid pocket 2, 1
• Nocturnal symptoms: Regurgitation and heartburn intensify during sleep when supine positioning facilitates reflux 2
• Central obesity and known hiatal hernia point to a mechanical etiology of gastroesophageal reflux 2

Acute Presentation (Emergency Symptoms)

• Severe epigastric pain with retching suggests hernia incarceration and requires urgent evaluation 1, 5
• Gastric volvulus symptoms: Intermittent obstruction and bleeding due to volvulus of the herniated stomach represent a potentially dangerous closed-loop obstruction 6, 1
• Signs of strangulation: Multiple episodes of vomiting with severe pain indicate possible bowel strangulation, which can progress to perforation, peritonitis, and sepsis 1, 5

Clinical Presentation Patterns

• Asymptomatic cases: Many hiatal hernias produce no symptoms and are incidental findings on imaging 4, 6
• Severe symptoms: Occur in 46% of congenital diaphragmatic hernias in adults 1
• Delayed diagnosis: Occurs in 5-45% of all congenital diaphragmatic hernias due to nonspecific presentation 1

Critical Diagnostic Pitfalls

• Normal chest radiographs can occur in 11-62% of diaphragmatic hernias, making clinical suspicion essential 1
• Right-sided hernias are more commonly missed, accounting for 50% of delayed diagnoses 1
• Initial radiographic misinterpretation occurs in approximately 25% of cases 1
• Isolated extra-esophageal symptoms have high PPI non-response rates because mechanisms other than GERD frequently contribute to symptom generation 2

Symptom Differences by Hernia Type

• Type I (sliding) hernias: Mimic GERD symptoms due to laxity in the lower esophageal sphincter, accounting for 90% of hiatal hernias 3, 2
• Type II (paraesophageal) hernias: Present with more severe respiratory symptoms and risk of volvulus, accounting for 10% of cases 2
• Type III and IV hernias: Can accommodate additional viscera (colon, spleen) and present with mixed obstructive and reflux symptoms 2