Hiatal Hernia Workup

Updated: Jan 02, 2016
  • Author: Waqar A Qureshi, MD, FRCP(UK), FACP, FACG, FASGE; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
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Workup

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) on 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 ga 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 the images below).

A paraesophageal hernia is seen on an upper gastro 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 gast 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 h 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 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 hernia 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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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 endos 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

Traditionally, esophageal manometry has had a low sensitivity for diagnosing hiatal hernia, as compared to endoscopy, and was therefore not appropriate in helping to establish a diagnosis. [6]

More recent studies with esophageal high-resolution manometry (HRM) appear to be more accurate for detecting hiatal hernias. In one study that evaluated the HRM recordings, endoscopy reports, and barium esophagograms of 90 patients, HRM had a 92% sensitivity and 95% specificity for identifying hiatal hernias compared with a 73% sensitivity each for endoscopy and radiography. [7]

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