Hiatal hernia

A hiatal (or hiatus) hernia is the abnormal protrusion of an abdominal structure into the thoracic cavity through a lax esophageal hiatus. Sliding hiatal hernias (type I), in which the gastroesophageal junction (GEJ) and the gastric cardia migrate into the thorax, account for 95% of hiatal hernias. In paraesophageal hernia (type II), only the gastric fundus herniates into the thorax, and in mixed hiatal hernias (type III), the GEJ and the gastric fundus herniate. Complex hiatal hernias (type IV) are rare and characterized by herniation of the stomach and other abdominal organs. Most patients with sliding hiatal hernias are asymptomatic and do not require medical or surgical intervention. Patients experiencing symptoms of gastroesophageal reflux disease (GERD) due to a sliding hiatal hernia can be treated with proton pump inhibitors or antireflux surgery and/or managed with lifestyle changes. Patients with paraesophageal hernia or mixed hiatal hernia may present with intermittent dysphagia, substernal discomfort, and/or abdominal pain, and, in rare cases, acute gastric volvulus and strangulation. Surgical intervention is necessary for symptomatic patients with paraesophageal, mixed, or complex hiatal hernias to prevent life-threatening complications.

For other diaphragmatic hernias, see “Congenital diaphragmatic hernias” and “Acquired diaphragmatic hernias.”

Protrusion of any abdominal structure/organ into the thorax through a lax diaphragmatic esophageal hiatus. In 95% of cases, a portion of the stomach is herniated.

• Incidence increases with:
  • Age: affects ∼ 70% of people > 70 years
  • ↑ BMI

Epidemiological data refers to the US, unless otherwise specified.

The etiology is multifactorial.

• Lax diaphragmatic esophageal hiatus
  • Advanced age
  • Smoking
  • Obesity
  • Genetic predisposition (rare) ^[1]
• Prolonged periods of increased intra-abdominal pressure
  • Pregnancy
  • Ascites
  • Chronic cough
  • Chronic constipation

Type I: sliding hiatal hernia ^[1]

• Most common type (95% of cases) ^[1]
• The GEJ and the gastric cardia slide up into the posterior mediastinum.
• The gastric fundus remains below the diaphragm (hourglass stomach)

Type II: paraesophageal hiatal hernia ^[1]

• Part of the gastric fundus herniates into the thorax.
• The GEJ remains in its anatomical position below the diaphragm.

Type III: mixed hiatal hernia ^[1]

• Mix of types I and II
• The GEJ and a portion of the gastric fundus prolapse through the hiatus.

Type IV: complex hiatal hernia ^[1]

• Herniation of any abdominal structure in addition to the stomach (e.g., spleen, colon)
• Rarest type

Anatomy

• Esophageal hiatus
  • Central opening of the diaphragm, which allows the esophagus to pass through into the peritoneal cavity; forms the lower part of the esophageal sphincter and the reflux barrier
  • Formed by:
    • Left and right paravertebral tendinous crura
    • Median arcuate ligament
• Gastroesophageal junction (GEJ)
  • Normally lies at the level of the esophageal hiatus
  • Phrenoesophageal ligament (PEL) attaches to the esophagus at the GEJ
    • Peritoneal fold that encircles the distal portion of the esophagus and gastroesophageal junction and connects them to the peritoneal surface of the diaphragm
    • Closes the esophageal hiatus and helps maintain the intra-abdominal position of the GEJ

Changes in the presence of a hiatal hernia

• Predisposing factors lead to laxity of the esophageal hiatus, e.g.:
  • Advanced age → phrenoesophageal ligament weakens
  • Smoking → loss of elastin fibres in the diaphragmatic crura
  • Obesity → deposition of fat in and around the crura → widened hiatus
• Relative negative intrathoracic pressure ; and the lax hiatus → herniation of the abdominal contents into the thorax → loss of reflux barrier + compromised fluid emptying of distal esophagus → gastroesophageal reflux disease (GERD)

• Type I hiatal hernia ^[2]
  • Most patients are asymptomatic.
  • Symptoms of GERD may be present.
• Type II hiatal hernia and type IV hiatal hernia ^[2]
  • Epigastric and/or substernal pain
  • Early satiety, nausea, vomiting
  • Postprandial dyspnea
  • Retching
  • Symptoms of GERD may be present.
• Type III hiatal hernia: combination of symptoms of other types

Hiatal hernias are often discovered incidentally on chest or abdomen imaging, especially when asymptomatic.

Approach ^[1][3]

• Only obtain confirmatory studies (e.g., barium swallow, upper endoscopy) if results are expected to alter treatment.
• Obtain urgent imaging (CT chest and abdomen) if acute complications (e.g., gastric outlet obstruction) are suspected. ^[4]
• For patients with symptoms of GERD, obtain GERD diagnostics.
• Consider additional studies as required for preoperative assessment, e.g., determining the extent of herniation.

Confirmatory studies ^[1][3][5]

• Barium swallow
  • Most sensitive study for hiatal hernia ^[6]
  • Used to evaluate hiatal hernia size and type
• Endoscopy
  • Used to evaluate hiatal hernia size and type and to assess for complications (e.g., Barrett esophagus) by evaluating mucosal condition
  • The location of the GEJ is determined using the Z-line (squamocolumnar junction).
    • Sliding hiatal hernia: Z-line lies > 2 cm above the diaphragmatic hiatus ^[3]
    • Paraesophageal hernia: Z-line remains undisplaced and the gastric fundus herniates through the hiatus

Imaging ^[1][5]

• Chest x-ray
  • Not usually indicated for evaluation of hiatal hernias ^[3]
  • Typical incidental findings
    • Types I, II, III: retrocardiac soft tissue opacity with or without air-fluid levels
    • Type IV: retrocardiac visceral gas (small bowel and/or colon) or soft tissue shadows (spleen or omentum)
• CT thorax: Used for urgent preoperative evaluation of paraesophageal hernias
  • Can help determine the type, size, and contents of the hernia
  • Can help detect acute complications (e.g., gastric perforation, gastric volvulus)

Additional diagnostics ^[1][5]

• Esophageal manometry
  • Helps calculate the size of a sliding hiatal hernia by identifying the level of the diaphragmatic hiatus
  • Can assess for esophageal motility disorders (e.g., achalasia) preoperatively
• Esophageal pH monitoring
  • Not diagnostic for hiatal hernias
  • Can determine the extent of gastroesophageal reflux

Obtain diagnostics for GERD in patients with sliding hiatal hernias before considering surgical treatment. ^[1]

Type I hiatal hernia ^[1][7]

Approach

• Asymptomatic patients: no treatment necessary
• Symptomatic patients
  • Begin conservative management.
  • Consider antireflux surgery in all patients with symptoms of GERD, especially for:
    • Failure or intolerance of conservative management
    • Large hiatal hernia
    • Complications of GERD (e.g., bleeding, strictures, ulcerations)

Conservative management

• Lifestyle modifications, e.g., avoidance of triggers such as nicotine
• Proton pump inhibitors
• See “Management of GERD” for details.
• See “Antacids and acid suppression medications” for PPI dosages.

Surgical techniques ^[2][3]

• Fundoplication, typically laparoscopic
• Hiatoplasty: reinforcement of the esophageal hiatus using sutures and/or mesh

Surgical repair of asymptomatic type I hiatal hernias is not recommended. ^[1]

All other types ^[1][2][3]

The following applies to type II hiatal hernia, type III hiatal hernia, and type IV hiatal hernia.

• Asymptomatic patients
  • Usually managed conservatively with watchful waiting until symptoms develop ^[3]
  • Select patients may benefit from surgery.
• Symptomatic patients: surgery indicated ^[8]
  • There is no standardized technique for paraesophageal hernia repair.
  • Techniques include: ^[7]
    • Hernia reduction and hernia sac excision
    • Closure of the hernia with hiatoplasty
    • Gastropexy/fundopexy: fixation of the gastric fundus to the diaphragm
    • Fundoplication

Type I hiatal hernia

• Arise from long-standing gastroesophageal reflux
• See "Complication of GERD.”

All other types

Strangulation and incarceration of herniated stomach and/or other intraabdominal organs can result in ischemic complications requiring emergent surgical intervention.

• Upper gastrointestinal bleeding (occult/massive) → iron deficiency anemia ^[9]
• Gastric ulcers
• Gastric perforation
• Gastric volvulus ^[1]
  • A rare condition characterized by abnormal rotation of the stomach
  • Can occur in the abdomen or chest (upside-down stomach)
  • Classified according to the rotational axis: organoaxial (around the long axis of the stomach) and mesenteroaxial (between the lesser and greater curvature)
• Total gastric outlet obstruction

The complications of type II hiatal hernia, type III hiatal hernia, and type IV hiatal hernia are often surgical emergencies.

We list the most important complications. The selection is not exhaustive.