What is a Hiatal Hernia?
A hiatal hernia is a condition where part of the stomach (and sometimes other abdominal organs) protrudes through the esophageal hiatus of the diaphragm into the thoracic cavity, occurring when the esophageal hiatus widens and allows herniation of gastric structures above the diaphragm. 1
Classification and Types
Hiatal hernias are categorized into four main types, each with distinct anatomical features 1:
Type I (Sliding Hiatal Hernia): Represents 90% of all hiatal hernias, where the esophageal hiatus widens, allowing the gastric cardia and gastroesophageal junction to migrate above the diaphragm 1, 2
Type II (Paraesophageal Hernia): Accounts for 10% of cases, involving a defect in the phrenoesophageal membrane that allows the gastric fundus to herniate while the gastroesophageal junction remains in its normal position 1
Type III (Mixed Hernia): Combines features of both Type I and II, with herniation of the gastric fundus and displacement of the gastroesophageal junction 1
Type IV (Complex Hernia): A large diaphragmatic hernia that can accommodate additional viscera including stomach, colon, and spleen 1
Clinical Presentation in Adults Over 50 with GERD History
Common Symptoms
The symptom profile varies significantly by hernia type and patient age 3:
Type I (Sliding) hernias typically present with GERD-like symptoms including heartburn, regurgitation, and chest pain due to laxity in the lower esophageal sphincter 2, 4
Larger paraesophageal hernias more commonly cause obstructive symptoms including dysphagia, vomiting, and discomfort from compression of adjacent organs 5
Adults specifically present most frequently with intermittent dysphagia (29-100% of cases) and food impaction (25-100% of cases) 3
Association with GERD
Type I sliding hiatal hernias are closely associated with GERD development and may lead to reflux esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. 4
The relationship follows the "two-sphincter hypothesis" where both anatomical (hiatal hernia) and physiological (lower esophageal sphincter) features play independent but important roles 4:
- The gastroesophageal junction becomes incompetent in patients with hiatal hernia 4
- Esophageal acid clearance is compromised, facilitating GERD development 4
- Hiatal hernia is identified as a risk factor for Barrett esophagus screening in men over 50 with chronic GERD 3
Risk Factors
Key predisposing factors include 2, 5:
- Advanced age (elderly patients are at higher risk)
- Obesity and elevated body mass index
- Intra-abdominal fat distribution 3
Diagnostic Approach
Imaging Modalities
Fluoroscopy with biphasic esophagram or upper GI series is the most useful test for diagnosing hiatal hernia and determining its size. 3, 6
The American College of Radiology recommends 3:
- Biphasic esophagram: Provides anatomic and functional information on esophageal length, strictures, presence of gastroesophageal reflux, and reflux esophagitis with 88% sensitivity
- Double-contrast upper GI series: Most beneficial for evaluating structural and functional abnormalities and detecting hiatal hernia presence and size
- Single-contrast studies: Have lower sensitivity (77%) but may still delineate the hernia and reveal reflux or strictures
Endoscopic Evaluation
The American College of Surgeons states that all patients considered for antireflux surgery require a barium esophagram 3. Upper endoscopy is indicated in specific circumstances 3:
- Men older than 50 years with chronic GERD symptoms (>5 years duration) and additional risk factors (nocturnal reflux, hiatal hernia, elevated BMI, tobacco use) to detect esophageal adenocarcinoma and Barrett esophagus 3
- Patients with typical GERD symptoms persisting despite 4-8 weeks of twice-daily PPI therapy 3
Clinical Significance and Complications
Potential Complications
Large hiatal hernias can cause serious complications 5, 7:
- Incarceration with tissue ischemia requiring acute surgical intervention 5
- Cardiac manifestations including arrhythmias (sinus tachycardia, atrial fibrillation, ventricular tachycardia), though rare 6, 7
- Tension gastrothorax potentially leading to cardiac arrest in severe cases 7
Warning Signs
Tachycardia combined with fever, continuous abdominal pain, and signs of systemic inflammatory response syndrome (SIRS) suggests strangulated hernia, a surgical emergency 3, 6
Management Considerations
Treatment depends on hernia type and severity 3, 4:
- Sliding hernias: Management similar to GERD treatment, reserved for symptomatic patients 4
- Complicated or large hernias: Surgery should be considered for refractory symptoms or complications (recurrent bleeding, ulcerations, strictures) 4
- Surgical approach: Minimally invasive techniques (laparoscopic/thoracoscopic) are now preferred when properly indicated, with shorter hospital stays and less morbidity compared to open surgery 3
The treatment approach for paraesophageal hernias differs significantly from sliding hiatal hernias, making accurate classification essential for appropriate management. 3