Hiatal Hernia Workup

  • Author: Waqar A Qureshi, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 5, 2012
 

Laboratory Studies

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

  • Barium upper gastrointestinal series
    • Although a chest radiograph may reveal a large hiatal hernia (see the first image below), 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 the second image below). Anteroposterior (left and lateral views (right) onAnteroposterior (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 gaBarium 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 the images below).A paraesophageal hernia is seen on an upper gastroA 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 gastParaesophageal 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 hBarium 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 the image below).A large paraesophageal hernia in which the entire 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 the image below) and subsequent incarceration and strangulation.Barium studies show gastric volvulus as the herniaBarium 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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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 the image 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 endosA 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.[5]
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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.

Specialty Editor Board

Vivek V Gumaste, MD  Associate Professor of Medicine, Mount Sinai School of Medicine of New York University; Adjunct Clinical Assistant, Mount 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Alex J Mechaber, MD, FACP  Senior 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

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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

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Hiatal hernia. Figure 1 shows the normal relationship of the gastroesophageal junction, stomach, esophagus, and diaphragm. Figure 2 shows a sliding hiatal hernia where the stomach immediately below the gastroesophageal junction is seen to prolapse through the diaphragmatic hiatus into the chest. Figure 3 shows a paraesophageal hernia in which the cardia or fundus of the stomach prolapses through the diaphragmatic hiatus, leaving the gastroesophageal junction within the esophageal cavity.
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.
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.
Barium radiograph view of a large paraesophageal hernia. Courtesy of David Y. Graham, MD.
A large paraesophageal hernia in which the entire stomach is seen in the chest cavity. Courtesy of David Y. Graham, MD.
Barium studies show gastric volvulus as the herniated stomach undergoes rotation. This situation requires surgical intervention. Courtesy of David Y. Graham, MD.
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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