Hiatus hernia may be asymptomatic or may present with heartburn, dysphagia, odynophagia, hoarseness, asthma, shortness of breath, chest pain, anaemia or haematemesis, or a combination of these.
Common risk factors are obesity and increased age. Other known risk factors include intra-abdominal pressure from various conditions, and a previous hiatus operation.
Contrasted upper gastrointestinal (GI) series (also known as an upper GI or as a barium oesophagram) is the key investigation technique and aids the surgeon in characterising any anatomical variation necessary for preoperative evaluation. Computed tomography scanning with 3-dimensional reconstruction can be helpful if the diagnosis is unclear, or when planning surgery.
The necessity for, and type of treatment, depends on the patient's symptoms and the anatomical configuration of the hernia.
Uncomplicated sliding hiatus hernias are treated symptomatically with medical therapy, although some patients may select surgical therapy. Complicated hiatus hernias (those with bleeding, volvulus, or obstruction) have a stronger indication for surgical repair.
Hiatus hernia is the protrusion of intra-abdominal contents into the thoracic cavity through an enlarged oesophageal hiatus of the diaphragm. Various subtypes exist which are are classified anatomically. A hiatus hernia most commonly contains a variable portion of the stomach (type I, II, or III); less commonly, it may contain the transverse colon, omentum, small bowel, or spleen, or some combination of these organs (type IV). Sliding type I hiatus hernias are generally differentiated from the remaining three types, which are collectively referred to as para-oesophageal hernias, and the herniated contents are usually contained within a sac of peritoneum.
History and exam
Key diagnostic factors
- presence of risk factors
- bowel sounds in chest
Other diagnostic factors
- chest pain
- shortness of breath
- non-bilious vomiting
- fever and chills
- increased age
- previous gastro-oesophageal procedure
- elevated intra-abdominal pressure
- male sex
- structural abnormalities of the oesophageal hiatus or the phreno-oesophageal ligaments
- incisional, umbilical, or inguinal hernia
- disorder of collagen metabolism
1st investigations to order
- chest x-ray
- contrast upper gastrointestinal series (barium oesophagram)
Investigations to consider
- CT scan or MRI scan
- high-resolution oesophageal manometry and pH monitoring
upper gastrointestinal haemorrhage and/or obstruction and/or volvulus
irreversible organ ischaemia and/or necrosis
symptomatic gastro-oesophageal reflux disease (GORD)
type I refractory to medical therapy or patient prefers surgery
types II, III, and IV
- Angina pectoris
- Gastro-oesophageal reflux disease (GORD)
- Informed consent for GI endoscopic procedures
- Consensus on non-variceal upper gastrointestinal bleeding: an update 2018
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