Hiatal Hernia :
It is the protrusion of the stomach up through the lax phrenico oesophageal
membranephageal hiatus of the diaphragm.
The type of hiatal hernia is defined by the location of the GE junction
and the relationship of the stomach to the distal esophagus.
1. In type I or sliding hiatal hernia
The phrenoesophageal membrane is intact but lax, thereby allowing the
distal esophagus and gastric cardia to herniated through the esophageal
hiatus. The GE junction is therefore located above the diaphragm. This
is the most common type and is usually asymptomatic.
2. A type II or paraesophageal hiatal hernia
Occurs when a focal defect is present in the phrenoesophageal membrane,
usually anterior and lateral to the esophagus, which allows a protrusion
of peritoneum to herniated upward alongside the esophagus through the
esophageal hiatus. The GE junction remains anchored within the abdomen,
whereas the greater curvature of the stomach rolls up into the chest
alongside the distal esophagus. Eventually, most of the stomach can
herniate. Because the stomach is anchored at the pylorus and cardia,
however, the body of the stomach undergoes a 180-degree organoaxial
rotation and ends up as an upside-down, intrathoracic stomach when it
3. Type III
Represents a combination of types I and II. This type is more common
than is a pure type II and is characterized by herniation of the greater
curvature of the stomach and the GE junction into the chest.
4. A type IV
In which abdominal organs other than or in addition to the stomach
herniate through the hiatus. Typically, these hernias are large and
contain colon or spleen in addition to the stomach within the chest.
Symptoms and complications
In patients with sliding (type I) hiatal hernias are related to associated
Para esophageal and combined (types II, III and IV) hernias frequently
produce post prandial pain or bloating, early, satiety, breathlessness
with meals and mild dysphagia related to compression of the distal esophagus
by the adjacent herniated stomach. The herniated gastric pouch is susceptible
to volvulus, obstruction and infarction and can develop ischemic ulcers
with frank or occult bleeding.
Diagnosis and Evaluation
1. Chest X-ray: The finding of an air-fluid level in the posterior
mediastinum on the lateral X-ray suggests the presence of a hiatal hernia.
Differential diagnosis includes mediastinal cyst, abscess, or a dilated
2. A barium swallow confirms the diagnosis and defines any coexisting
esophageal abnormalities, including strictures or ulcers, and is the
diagnostic study of choice. The positions of the GE junction and proximal
stomach define the type of hiatal hernia.
3. Esophago gastro duodenoscopy (EGD) is indicated in patients with
symptoms of reflux or dysphagia to determine the degree of esophagitis,
presence of a stricture, Barrett's esophagus or a coexisting abnormality.
EGD also establishes the location of the GE junction in relation to
the hiatus. A sliding hiatal hernia is present when 2 cm or more of
gastric mucosa is present between the diaphragmatic hiatus and the mucosal
squamo columnar junction.
4. Esophageal manometry to evaluate esophageal motility is warranted
in patients who are being considered for operative repair.
1. Asymptomatic sliding hernias require no treatment.
2. Patients with sliding hernias and GER with mild esophagitis should
undergo an initial trial of medical management.
3. Patients who fail to obtain symptomatic relief with medical therapy
or who have severe esophagitis should undergo esophageal testing to
determine their suitability for an antireflux procedure and hiatal hernia
4. Patients who do not experience reflux but have symptoms related
to their hernia (chest pain, intermittent dysphagia, or esophageal obstruction)
should undergo hiatal hernia repair.
5. All patients who are found to have a type II, III or IV hiatal hernia
and who are operative candidates should be considered for repair. Medically
treated patients with a Para esophageal hernia, even when asymptomatic
have nearly a 30% incidence of death from the development of a catastrophic
complication. Operative repair can be performed through either an abdominal
or thoracic approach and consists of reduction of the hernia, resection
of the sac, and closure of the hiatal defect. In combined (type III)
hernias, the esophagus frequently is shortened, and therefore a thoracic
approach is preferred.
6. Para esophageal hiatal hernias are associated with a 60% incidence
of GER. Furthermore, the operative dissection may lead to postoperative
GER in previously asymptomatic patients. Therefore, an antireflux procedure
should be performed at the time of hiatal hernia repair.