The term hiatus hernia refers to the herniation of a part of the abdominal viscera through the oesophageal aperture of the diaphragm. The vast majority of hiatus hernias involve only the herniation of a part of the gastric cardia through the muscular hiatal aperture of the diaphragm; however, rarely, hernias with a large defect can allow other organs to enter the thoracic cavity, such as the spleen and pancreas.

Epidemiology¹

The precise incidence of hiatus hernia is not known, as most studies have looked only at individuals who presented with symptoms of dyspepsia. Of patients undergoing investigation for dyspepsia in western populations, approximately 15-25% are discovered to have a hiatus hernia.² It is more common amongst men.³ The incidence increases with age and obesity but varies from country to country, being more common in western societies and rare in the Far East. This is thought to be due to dietary differences, the lower-fibre diet of western countries leading to chronic constipation and straining during bowel movements.¹

Risk factors

• Obesity.
• Pregnancy.
• Ascites.
• Advanced age.
• Conditions causing shortening of the oesophagus, such as chronic oesophagitis (by virtue of scarring).

Aetiology^1,4

A hiatus hernia may be caused by one or more of three possible mechanisms:

• Widening of the diaphragmatic hiatus.
• Pulling up of the stomach, due to oesophageal shortening.
• Pushing up of the stomach by increased intra-abdominal pressure.

Acute hiatus hernia has been reported as a late complication of gastrectomy.⁵

There are two types

Sliding hiatus hernia - the gastro-oesophageal junction slides up into the thoracic cavity (80% of cases).

Presentation¹

Many individuals with a hiatus hernia will be totally asymptomatic; others may present with any of the following:

• Retrosternal burning sensation or "heartburn", especially on bending or lying.
• Flatulence.
• Gastro-oesophageal reflux.
• Rarely, difficulty in swallowing.

There appears to be no correlation between the size of the hernia and the severity of symptoms.

Examination is usually normal unless an underlying risk factor is present.

Investigations

• Barium studies remain the only accurate method of measuring the size of a hiatus hernia.
• Hiatus hernia is sometimes seen as an incidental finding when the patient is being endoscoped for investigation of dyspepsia.
• Oesophageal manometry is not sufficiently sensitive for diagnostic purposes, especially with small hernias.

Associated diseases

• Barrett's oesophagus - there is a strong link with hiatus hernia.⁶
• Oesophageal adenocarcinoma - presence of a hiatus hernia is associated with a sixfold increased risk, which increases to eightfold if reflux is also present.⁷
• Reflux laryngitis.⁸

Complications¹

Rare complications include gastric volvulus and strangulation (up to 5% of para-oesophageal hernias).

Management¹

Nondrug

• Patients with hiatus hernia should be advised to avoid any factors likely to increase intra-abdominal pressure, e.g. tight clothing, corsets.
• Nocturnal symptoms may be helped by elevating the head of the bed to reduce postural reflux.
• Weight loss should be advised in obese patients, and patients who smoke and/or drink alcohol should be encouraged to stop.

Differential diagnoses

• Angina.¹
• Rumination syndrome - self-induced regurgitation from the stomach to the mouth, caused by a voluntary rise in intra-abdominal and intra-gastric pressure, leading to the reflux of the gastric content into the oesophagus⁹

Drugs

• Symptomatic relief may be gained by the use of alginates +/- use of proton pump inhibitors, although patients with hiatus hernia may require larger doses for symptom control.

Surgical

• The presence of a hiatus hernia is a marker for severe gastro-oesophageal reflux disease (GORD). Patients with a hiatus hernia tend to have more severe symptoms and a poorer response to treatment but its presence per se does not alter management strategies.
• Indications for surgery in patients with severe GORD include:
  • Patients who are unable to comply with therapeutic regimes.
  • Patients who require high doses of drugs.
  • Patients who wish to avoid lifelong medical treatment.
  • Patients with respiratory complications of reflux, such as asthma.
  • Para-oesophageal hernia - elective surgery may be recommended due to the high incidence of strangulation.
• The surgical procedure most commonly used involves mobilising the oesophagus in the thorax, bringing it down to restore the intra-abdominal portion and repairing the deficit (modified Nissen's procedure). Recurrence of the hernia after this procedure is not unknown.¹⁰
• Oesophageal lengthening combined with fundoplication may be performed during laparoscopic surgery.
• Several novel endoscopic techniques have been used in the treatment of GORD with some success but the results do not separate out patients with hiatus hernia.

Prognosis¹

The majority of patients will gain symptomatic relief from medical or surgical intervention, although a few will continue to have symptoms. Morbidity and mortality in patients undergoing laparoscopic hernia repair is higher in those aged over 70.

Document references

1. Qureshi WA; Hiatal Hernia, Medscape, Aug 2009
2. Gordon C, Kang JY, Neild PJ, et al; The role of the hiatus hernia in gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2004 Oct 1;20(7):719-32. [abstract]
3. Menon S, Trudgill N; Risk factors in the aetiology of hiatus hernia: a meta-analysis. Eur J Gastroenterol Hepatol. 2011 Feb;23(2):133-8. [abstract]
4. Weber C, Davis CS, Shankaran V, et al; Hiatal hernias: a review of the pathophysiologic theories and implication for Surg Endosc. 2011 Apr 29. [abstract]
5. Piciucchi S, Milandri C, Verdecchia GM, et al; Acute hiatal hernia: a late complication following gastrectomy. Int Arch Med. 2010 Oct 4;3:23. [abstract]
6. Lord RV, DeMeester SR, Peters JH, et al; Hiatal hernia, lower esophageal sphincter incompetence, and effectiveness of J Gastrointest Surg. 2009 Apr;13(4):602-10. Epub 2008 Dec 3. [abstract]
7. Wu AH, Tseng CC, Bernstein L; Hiatal hernia, reflux symptoms, body size, and risk of esophageal and gastric adenocarcinoma. Cancer. 2003 Sep 1;98(5):940-8. [abstract]
8. Lien HC, Wang CC, Hsu JY, et al; Classical reflux symptoms, hiatus hernia and overweight independently predict Aliment Pharmacol Ther. 2011 Jan;33(1):89-98. doi: [abstract]
9. Gourcerol G, Dechelotte P, Ducrotte P, et al; Rumination syndrome: When the lower oesophageal sphincter rises. Dig Liver Dis. 2011 Jul;43(7):571-4. Epub 2011 Feb 16. [abstract]
10. Fei L, del Genio G, Rossetti G, et al; Hiatal hernia recurrence: surgical complication or disease? Electron microscope J Gastrointest Surg. 2009 Mar;13(3):459-64. Epub 2008 Nov 26. [abstract]

Internet and further reading

• Siau K, Khanna A, Abdul-Wahab T; Incarceration of a paraoesophageal hiatus hernia. Int J Emerg Med. 2010 Oct 23;3(4):517.
• Pandolfino JE, Kwiatek MA, Ho K, et al; Unique features of esophagogastric junction pressure topography in hiatus hernia Surgery. 2010 Jan;147(1):57-64. Epub 2009 Jul 18. [abstract]