eMedicine Specialties > Gastroenterology > Esophagus

Hiatal Hernia: Differential Diagnoses & Workup

Author: Waqar A Qureshi, MD, Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Aug 24, 2009

Overview
Differential Diagnoses & Workup
Treatment & Medication
Follow-up
Multimedia

Differential Diagnoses

Angina Pectoris

Workup

Laboratory Studies

The typical reasons for evaluation are symptoms of GERD or a chest radiograph suggesting a paraesophageal hernia.

Imaging Studies

Barium upper gastrointestinal series
- Although a chest radiograph may reveal a large hiatal hernia (see Media file 2), and many incidentally diagnosed hiatal hernias are discovered in this manner, a barium study of the esophagus helps establish the diagnosis with greater accuracy (see Media file 3).
  Anteroposterior (left and lateral views (right) on a chest radiograph showing a large hiatal hernia. Courtesy of David Y. Graham, MD.
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  Anteroposterior (left and lateral views (right) on a chest radiograph showing a large hiatal hernia. Courtesy of David Y. Graham, MD.
  
  Barium study shows a sliding hiatal hernia: The gastric folds can be seen extending above the diaphragm. Courtesy of David Y. Graham, MD.
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  Barium study shows a sliding hiatal hernia: The gastric folds can be seen extending above the diaphragm. Courtesy of David Y. Graham, MD.
- Typical findings include an outpouching of barium at the lower end of the esophagus, a wide hiatus through which gastric folds are seen in continuum with those in the stomach, and, occasionally, free reflux of barium.
- A barium study helps distinguish a sliding from a paraesophageal hernia (see Media files 4-6).
  A paraesophageal hernia is seen on an upper gastrointestinal series. Note that the gastroesophageal junction remains below the diaphragm. Courtesy of David Y. Graham, MD.
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  A paraesophageal hernia is seen on an upper gastrointestinal series. Note that the gastroesophageal junction remains below the diaphragm. Courtesy of David Y. Graham, MD.
  
  Paraesophageal hernia is seen on barium upper gastrointestinal series. The mucosal folds are seen going up into the chest, next to the esophagus. Courtesy of David Y. Graham, MD.
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  Paraesophageal hernia is seen on barium upper gastrointestinal series. The mucosal folds are seen going up into the chest, next to the esophagus. Courtesy of David Y. Graham, MD.
  
  Barium radiograph view of a large paraesophageal hernia. Courtesy of David Y. Graham, MD.
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  Barium radiograph view of a large paraesophageal hernia. Courtesy of David Y. Graham, MD.
  In rare cases, the entire stomach may herniate into the chest (see Media file 7).
  A large paraesophageal hernia in which the entire stomach is seen in the chest cavity. Courtesy of David Y. Graham, MD.
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  A large paraesophageal hernia in which the entire stomach is seen in the chest cavity. Courtesy of David Y. Graham, MD.
  The stomach may then undergo volvulus (see Media file 8) and subsequent incarceration and strangulation.
  Barium studies show gastric volvulus as the herniated stomach undergoes rotation. This situation requires surgical intervention. Courtesy of David Y. Graham, MD.
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  Barium studies show gastric volvulus as the herniated stomach undergoes rotation. This situation requires surgical intervention. Courtesy of David Y. Graham, MD.

Procedures

Endoscopy
- Hiatal hernia is diagnosed easily using upper gastrointestinal endoscopy.
- The diagnosis of a hiatal hernia actually is incidental, and endoscopy is used to diagnose complications such as erosive esophagitis, ulcers in the hiatal hernia, Barrett esophagus, or tumor.
- A hiatal hernia is confirmed when the endoscope is about to enter the stomach or on retrograde view once inside the stomach (see Media file 9 or below). If any doubt remains, the patient may be asked to sniff through the nose, which causes the diaphragmatic crura to approximate, seen as a pinch, closing the lumen.
  A retrograde view of a hiatal hernia seen at endoscopy shows the gastric folds to the left of the scope shaft extending up into the hernia. Courtesy of David Y. Graham, MD.
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  A retrograde view of a hiatal hernia seen at endoscopy shows the gastric folds to the left of the scope shaft extending up into the hernia. Courtesy of David Y. Graham, MD.
- Endoscopy also permits biopsy of any abnormal or suspicious area.
- Esophageal manometry has a low sensitivity for diagnosing hiatal hernia, as compared to endoscopy, and is therefore not appropriate in helping to establish a diagnosis.⁴

More on Hiatal Hernia

Overview: Hiatal Hernia

Differential Diagnoses & Workup: Hiatal Hernia

Treatment & Medication: Hiatal Hernia

Follow-up: Hiatal Hernia

Multimedia: Hiatal Hernia

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Keywords

hiatal hernia, hernias, paraesophageal hernias, paraesophageal hiatal hernia, esophageal hernia, hernia surgery, gastroesophageal reflux disease, GERD, gastric volvulus, hiatus hernia, Schatzki ring, phrenoesophageal ligament, esophagitis, Cameron ulcers, sliding hiatal hernia, regurgitation

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Contributor Information and Disclosures

Author

Waqar A Qureshi, MD, Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center
Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Vivek V Gumaste, MD, Associate Professor of Medicine, Mt Sinai School of Medicine; Adjunct Clinical Assistant, Mt Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center
Vivek V Gumaste, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Oscar S Brann, MD, FACP, Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group
Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

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