Hiatal Hernia Clinical Presentation

Updated: Sep 05, 2019
  • Author: Waqar A Qureshi, MD, FRCP(UK), FACP, FACG, FASGE; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
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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.