History and Physical Examination
Hiatal hernias are relatively common and, in themselves, do not cause symptoms. For this reason, most people with hiatal hernias are asymptomatic. Hiatal hernias may predispose to reflux or worsen existing reflux in a minority of individuals. Physicians should resist the temptation to label hiatal hernia as a disease.
Patients can have reflux without a demonstrable hiatal hernia. When a hernia is present in a patient with symptomatic GERD, the hernia may worsen symptoms for several reasons, including the hiatal hernia acting as a fluid trap for gastric reflux and increasing the acid contact time in the esophagus. In addition, with a hiatal hernia, episodes of transient relaxation of the LES are more frequent and the length of the high-pressure zone is reduced. The main symptoms of a sliding hiatal hernia are those associated with reflux and its complications.
No clear correlation exists between the size of a hiatal hernia and the severity of the symptoms. A very large hiatal hernia may be present with no symptoms at all. Some complications are specific for a hiatal hernia.
Esophageal complications
By far, the majority of hiatal hernias are asymptomatic. Often, patients are left with the impression that they have a disease when a hiatal hernia is diagnosed.
In rare cases, however, a hiatal hernia may be responsible for intermittent bleeding from associated esophagitis, erosions (Cameron ulcers), or a discrete esophageal ulcer, leading to iron-deficiency anemia. The prevalence of large hiatal hernias in patients with iron deficiency anemia is 6%-7%. This particular complication is more likely in patients who are bed-bound or those who take nonsteroidal anti-inflammatory drugs. Massive bleeding is rare.
Nonesophageal complications
Incarceration of a hiatal hernia is rare and is observed only with paraesophageal hernia. When incarceration occurs, it can present abruptly, with a sudden onset of vomiting and pain, sometimes requiring immediate operative intervention.
The physical examination usually is unhelpful. Certain conditions predispose to the development of hiatus hernia. These include obesity, pregnancy, and ascites.
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Hiatal Hernia. Figure 1 shows the normal relationship of the gastroesophageal (GE) junction, stomach, esophagus, and diaphragm. Figure 2 shows a sliding hiatal hernia, in which the stomach immediately below the GE 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 GE junction within the esophageal cavity.
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Hiatal Hernia. These 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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Hiatal Hernia. This barium study shows a sliding hiatal hernia: The gastric folds can be seen extending above the diaphragm. GE = gastroesophageal. Courtesy of David Y Graham, MD.
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Hiatal Hernia. A paraesophageal hernia is seen on an upper gastrointestinal radiograph series. Note that the gastroesophageal (GE) junction remains below the diaphragm. Courtesy of David Y Graham, MD.
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Hiatal Hernia. A paraesophageal hernia is seen on a barium upper gastrointestinal radiograph series. The mucosal folds are seen going up into the chest, next to the esophagus. GE = gastroesophageal. Courtesy of David Y Graham, MD.
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Hiatal Hernia. This image is a barium radiograph view of a large paraesophageal hernia. GE = gastroesophageal. Courtesy of David Y Graham, MD.
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Hiatal Hernia. This barium radiograph shows 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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Hiatal Hernia. These 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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Hiatal Hernia. 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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Hiatal Hernia. Inderpal S Sarkaria, MD, discusses the options for paraesophageal hernia repair. Courtesy of Memorial Sloan-Kettering Cancer Center.
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Hiatal Hernia. This image shows a Linx device in place during laparoscopic surgery. Courtesy of Shawn S Groth, MD, MS, FACS.
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Hiatal Hernia. This image demonstrates a Linx device in place on x-ray. Courtesy of Shawn S Groth, MD, MS, FACS.
