Approach Considerations
The typical reasons for evaluation are symptoms of GERD or a chest radiograph suggesting a paraesophageal hernia.
A mass lesion in the central chest could be confused with a hiatal hernia.
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).
Hiatal Hernia. These anteroposterior (left) and lateral views (right) on a chest radiograph showing a large hiatal hernia. Courtesy of David Y Graham, MD.
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.
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).
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.
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.
Hiatal Hernia. This image is a barium radiograph view of a large paraesophageal hernia. GE = gastroesophageal. Courtesy of David Y Graham, MD.
In rare cases, the entire stomach may herniate into the chest (see the image below).
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.
The stomach may then undergo volvulus (see the image below) and subsequent incarceration and strangulation.
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.
See Hiatal Hernia Imaging for more information.
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.
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.
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. [7]
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. [8]
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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.
