General Information

Description:
herniation of stomach through esophageal hiatus of diaphragm (2)

Also called:
hiatus hernia(2)
sliding hiatal hernia

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Definitions:
information in this topic deals with type I (sliding hiatal hernias)

Types:
type I(2)

sliding hiatal hernia

most common, 90% of hiatal hernias
widening of muscular hiatal aperture of diaphragm
laxity of phrenoesophageal membrane
allows some of gastric cardia to herniate upwards
type II

paraesophageal hernia(2)
results from localized defect in phrenoesophageal membrane (2)
gastroesophageal junction stays fixed to preaortic fascia and arcuate ligament (2)
gastric fundus forms leading part of herniation (2)
review of paraesophageal ("rolling") type can be found in Pediatric Surgery
Update 2004 Aug;23(2):2
type III(2)

result from mixed types I and II hernias with sliding aspect to type II

if associated with large defect, may allow herniation of other organs (spleen,
pancreas)

Organs involved:
stomach(2)
common disorder of gastroesophageal junction(2)

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Who is most affected:

frequency increases with age(2)
no definitive gender predilection(2)

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Incidence/Prevalence:
prevalence unclear(2)

most studies based on patients requiring upper endoscopy, rather than

community-based population

difficult to determine due to asymptomatic patients(2)

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possible geographical variation in prevalence(2)

less prevalent in far east

more prevalent in western world

unclear as to whether this variation is due to genetic or lifestyle variation or to

patient selection and diagnostic criteria
Causes and Risk Factors
o

Causes:
o

o
o
o

1 or more of 3 mechanisms may be involved(2)

widening of diaphragmatic hiatus
pulling up of stomach by esophageal shortening
pushing up of stomach by increased intra-abdominal pressure
possible autosomal dominant inheritance(2)
congenital (rare) (Prenat Diagn 2004 Jan;24(1):26)
acquired (traumatic) hiatal hernia uncommon

review of traumatic diaphragmatic hernia can be found in Pediatric Surgery

Update 2006 Jun;26(6):1

Possible risk factors:

age(2)
obesity(2)
power-lifting athletes(2)

prevalence of up to 80%

may be associated with repeated raised intra-abdominal pressure

Complications and Associated Conditions
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o
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Complications:
o

gastrointestinal complications
gastroesophageal reflux(1)
may inhibit ability of acid suppressing medication to normalize intraesophageal
pH(2)

in about 33% of patients with untreated paraesophageal hernias (2)

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intrathoracic incarceration of stomach
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bleeding
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strangulation
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perforation

abnormal esophageal acid exposure(2)

gastric volvulus (Presse Med 2008 Mar;37(3 Pt 2):e67 [French])

with very large hernias, compression of adjacent structures can occur and result in (1)

cardiac compression (rare)

syncope

dyspnea
recurrent volvulus after paraesophageal hernia repair described in case report (Surg
Endosc 2001 Jul;15(7):757)

Associated conditions:
esophagitis(2)
Barrett esophagus(2)
esophageal cancer(2)
mitral valve prolapse associated with hiatal hernia

23 children with endoscopically and radiographically verified hiatal hernia

18 found to have mitral valve prolapse

Reference - Eur J Pediatr 1997 Jan;156(1):35

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gastrointestinal stromal tumor described in case report (J Med Invest 2002 Aug;49(34):186)
History and Physical
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History:
Chief concern (CC):
o
o
o

may be asymptomatic(2)
gastroesophageal reflux, however, may or may not be asymptomatic(1)
with larger hernias(1)

syncope or dyspnea (termed "swallow syncope" syndrome), especially in elderly

patients

dyspnea, edema, or reduced exercise tolerance with heart failure

Family history (FH):

o

family clusters have been reported(2)

Physical:
General physical:
o
physical exam unremarkable
o
see also gastroesophageal reflux disease
Diagnosis

Making the diagnosis:

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o

consensus on diagnosis requires lower esophageal ring to be > 1-2 cm above level of
diaphragmatic hiatus, however distinction is arbitrary in practice (2)
upper gastrointestinal endoscopy(2)

hiatus hernia present if diaphragmatic indentation seen 2 cm distal to Z-line

(gastroesophageal junction) and top of stomach mucosal folds
diagnosis made through imaging studies (2)

large hiatal hernias easily diagnosed by radiological, endoscopic and manometric

studies

small hiatus hernia diagnosis not standardized

gastroesophageal junction moves during swallowing (2)

Rule out:
o
o
o

left atrial mass(1)

gastroesophageal flap valve (J Gastroenterol 2006 Jul;41(7):720)
differentiate from

congenital diaphragmatic hernia

herniation or eventration of the diaphragm with gastric volvulus

esophageal duplication

para-esophageal gastric herniation

Reference - Prenat Diagn 2004 Jan;24(1):26

Testing overview:
upper gastrointestinal endoscopy(2)
ultrasound(1)
x-ray(2)
transesophageal echocardiogram if cardiac involvement(1)

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o
o
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Imaging studies:
upper gastrointestinal endoscopy(2)
hiatus hernia present if diaphragmatic indentation seen 2 cm distal to Z-line
and top of stomach mucosal folds

to assess upper gastrointestinal symptoms

o
esophageal manometry NOT sensitive for diagnosis(2)
o
prenatal diagnosis via ultrasound has been reported in several cases (1)
Treatment
o

Treatment overview:
o
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treatment (surgery) may not be necessary

for treatment of symptoms of reflux, see gastroesophageal reflux disease

Surgery and procedures:

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o

surgery may be done laparoscopically, but large hiatus hernia may require laparotomy (2)
anterior hiatal repair during laparoscopic Nissen fundoplication may reduce
dysphagia for lumpy solids compared to posterior hiatal repair (level 2 [midlevel] evidence)

based on randomized trial without intention-to-treat analysis

102 patients with hiatal hernia having laparoscopic Nissen fundoplication

randomized to anterior hiatal repair vs. posterior hiatal repair and followed for 10
years

84% analyzed at 10 years

dysphagia for lumpy solids in 14% with anterior hiatal repair vs. 39.5% with
posterior hiatal repair (p = 0.01, NNT 4)

no significant difference in
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heartburn
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regurgitation
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epigastric pain
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postoperative dysphagia for liquids or soft solids
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patient satisfaction

Reference - World J Surg 2011 Sep;35(9):2038

prosthetic reinforcement of cruroplasty may prevent recurrences in large

hiatal hernias (level 2 [mid-level] evidence)

based on randomized trial with allocation concealment and methods of

randomization not stated

72 patients having laparoscopic Nissen fundoplication who had hernia defect 8

cm were randomized to posterior cruroplasty vs. posterior cruroplasty plus
polytetrafluoroethylene mesh

comparing cruroplasty alone vs. cruroplasty plus mesh

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22% vs. 0 had hernia recurrences (p < 0.006, NNT 5)
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mesh associated with longer operative time and $960 increase in cost of
repair

Reference - Arch Surg 2002 Jul;137(6):649 full-text

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biologic prosthesis reported to reduce recurrence after laparoscopic
paraesophageal hernia repair (level 3 [lacking direct] evidence)

based on randomized trial with no clear difference in clinical outcomes

108 patients having laparoscopic paraesophageal hernia repair randomized to

primary repair vs. primary repair buttressed with small intestinal submucosa

both groups had similar reductions in symptoms and improved quality of life at 6
months

among 90% of patients who had upper GI x-ray at 6 months, 24% primary repair
group vs. 9% biologic prosthesis group had recurrent hernia > 2 cm (p = 0.04, NNT 8)

Reference - Ann Surg 2006 Oct;244(4):481 full-text

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paraesophageal hiatus hernia progression for 8 years and subsequent treatment with
laparoscopic surgery without recurrence described in case report (Hepatogastroenterology
2002 Jul-Aug;49(46):992)
Prognosis
o
prognosis unclear(2)

unknown as to how hiatal hernia influences pathogenesis, progression,

complications, and effects of therapy of gastroesophageal reflux disease (GERD)

presence of hiatal hernia does not alter management strategies of GERD

o
may recur after laparoscopic paraesophageal hernia repair (Surg Laparosc Endosc
Percutan Tech 2006 Oct;16(5):301)
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presence of hiatal hernia may indicate risk factor for progressive reflux esophagitis

based on cohort study

155 patients with mild reflux esophagitis were followed without treatment, by
endoscopy, for mean 5.5 years after initial diagnosis

11 patients (10.5%) progressed to more severe esophagitis

Reference - J Gastroenterol Hepatol 2002 Sep;17(9):949

Prevention and Screening
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not applicable
Guidelines and Resources
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Guidelines:
o
o

no relevant guideline for "hiatal hernia" or "hiatus hernia" found 2012 Dec 5 on
systematic search of MEDLINE (using guidelines limiter) and National Guideline
Clearinghouse
see Gastroesophageal reflux disease (GERD) for related guidelines

Review articles:
o
o

case presentation of paraesophageal hernia can be found in CMAJ 2007 Jan

2;176(1):37 full-text
discussion can be found in Pediatric Surgery Update 2000 Jul;15(1):2