Hiatus Hernia

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oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

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.

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.[1] It is more common amongst men.[2] The incidence increases with age and obesity.[1] Differences in definitions and methodology make comparisons of epidemiological data difficult but studies suggest the prevalence may be lower among Asian and Afro-Caribbean subjects compared with Caucasians.[3] 

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Risk factors

  • Obesity.[4] 
  • Pregnancy.[5] 
  • Ascites.[6] 
  • Advanced age.[2] 
  • Genetic predisposition.[5] 
  • Conditions causing shortening of the oesophagus, such as chronic oesophagitis. Shortening is thought to occur by virtue of reflex contraction of oesophageal longitudinal muscle, evoked by intraluminal acid.[5] 

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.[8]

There are two types

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

Sliding Hiatus Hernia

Rolling hiatus hernia - the gastro-oesophageal junction remains in place but a part of the stomach herniates into the chest next to the oesophagus (20% of cases).

Rolling hiatus hernia

The association between hiatus hernia and oesophagitis has been recognised for over 70 years; however, it is only much more recently that the precise relationship between the two has been understood. It is now believed that the hiatus hernia has major pathophysiological effects resulting in gastro-oesophageal reflux and contributing to mucosal injury, particularly in patients with severe gastro-oesophageal reflux disease (GORD).

An alternative classification according to anatomical features has been produced as follows:[9] 

  • Type I: sliding hiatal hernias, where the gastro-oesophageal junction migrates above the diaphragm. The stomach remains in its usual longitudinal alignment and the fundus remains below the gastro-oesophageal junction.
  • Type II: pure para-oesophageal hernias where the gastro-oesophageal junction remains in its normal anatomic position but a portion of the fundus herniates through the diaphragmatic hiatus adjacent to the oesophagus.
  • Type III: a combination of types I and II where both the gastro-oesophageal junction and the fundus herniate through the hiatus. The fundus lies superior to the gastro-oesophageal junction.
  • Type IV: structures other than stomach, such as the omentum, colon or small bowel, lie within the hernia sac.

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.

  • Barium studies remain the only accurate method of measuring the size of a hiatus hernia.
  • Hiatus hernia is increasingly being diagnosed by endoscopy.
  • Oesophageal manometry is mostly used for the diagnosis of oesophageal motility disorders but has been used to help diagnose hiatus hernia.

Rare complications include gastric volvulus and strangulation (a recognised para-oesophageal hernias).[9][14] 

  • Angina.[15] 
  • Rumination syndrome - self-induced regurgitation from the stomach to the mouth, caused by a voluntary rise in intra-abdominal and intragastric pressure, leading to the reflux of the gastric content into the oesophagus.[16] 

Non-drug

Non-drug measures to minimise symptoms are the same as those advocated to minimise GORD:

  • Patients with hiatus hernia should be advised to avoid any factors likely to increase intra-abdominal pressure - eg, 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.

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

  • Asymptomatic patients with type 1 hernias do not need surgery.
  • 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.
  • All symptomatic para-oesophageal hernias should be repaired, especially if acute obstructive symptoms develop or volvulus has occurred.
  • Asymptomatic para-oesophageal hernias may not always require surgery. The patient's age and any comorbidities should be taken into account.
  • 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). The trans-thoracic or trans-abdominal route may be used.
  • Laparoscopic surgery is as effective as, and less hazardous than, open surgery.
  • Use of a mesh to reinforce large hernia repairs reduces short-term recurrence rates but the long-term benefits are unknown.
  • Oesophageal lengthening combined with fundoplication may be performed during laparoscopic surgery.
  • Gastropexy (suturing of the stomach to the abdominal wall) is sometimes used in addition to hiatus hernia repair or may be used as the sole procedure in high-risk patients.
  • Trials using endoscopic techniques used in the treatment of GORD with or without hiatus hernia have reported a high rate of complications and are not currently advocated.[17] 

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.

Further reading & references

  1. 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.
  2. 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.
  3. Kang JY; Systematic review: geographical and ethnic differences in gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2004 Oct 1;20(7):705-17.
  4. Che F, Nguyen B, Cohen A, et al; Prevalence of hiatal hernia in the morbidly obese. Surg Obes Relat Dis. 2013 Nov-Dec;9(6):920-4. doi: 10.1016/j.soard.2013.03.013. Epub 2013 Apr 19.
  5. Hyun JJ, Bak YT; Clinical significance of hiatal hernia. Gut Liver. 2011 Sep;5(3):267-77. doi: 10.5009/gnl.2011.5.3.267. Epub 2011 Aug 18.
  6. Khouzam RN, Akhtar A, Minderman D, et al; Echocardiographic aspects of hiatal hernia: A review. J Clin Ultrasound. 2007 May;35(4):196-203.
  7. Weber C, Davis CS, Shankaran V, et al; Hiatal hernias: a review of the pathophysiologic theories and implication for Surg Endosc. 2011 Apr 29.
  8. Piciucchi S, Milandri C, Verdecchia GM, et al; Acute hiatal hernia: a late complication following gastrectomy. Int Arch Med. 2010 Oct 4;3:23.
  9. Guidelines for the Management of Hiatal Hernia; Society of American Gastrointestinal and Endoscopic Surgeons, 2013
  10. Stylopoulos N, Rattner DW; The history of hiatal hernia surgery: from Bowditch to laparoscopy. Ann Surg. 2005 Jan;241(1):185-93.
  11. 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.
  12. 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.
  13. 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:
  14. Stylopoulos N, Gazelle GS, Rattner DW; Paraesophageal hernias: operation or observation? Ann Surg. 2002 Oct;236(4):492-500; discussion 500-1.
  15. Koskinas KC, Oikonomou K, Karapatsoudi E, et al; Echocardiographic manifestation of hiatus hernia simulating a left atrial mass: case report. Cardiovasc Ultrasound. 2008 Sep 15;6:46. doi: 10.1186/1476-7120-6-46.
  16. 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.
  17. Jobe BA; Endoscopic treatments for gastroesophageal reflux disease. Gastroenterol Hepatol (N Y). 2012 Jan;8(1):42-4.
  18. Larusson HJ, Zingg U, Hahnloser D, et al; Predictive factors for morbidity and mortality in patients undergoing laparoscopic paraesophageal hernia repair: age, ASA score and operation type influence morbidity. World J Surg. 2009 May;33(5):980-5. doi: 10.1007/s00268-009-9958-9.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Prof Cathy Jackson
Current Version:
Peer Reviewer:
Dr Helen Huins
Document ID:
2259 (v23)
Last Checked:
26/02/2014
Next Review:
25/02/2019