Hiatal hernia

Last reviewed: April 2018

Last updated: November 2017

Summary

Protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm.

Risk factors include obesity, increased intra-abdominal pressure from various conditions, and a previous hiatal operation.

May be asymptomatic or may present with heartburn, dysphagia, odynophagia, hoarseness, asthma, shortness of breath, chest pain, anaemia or haematemesis, or some combination of these.

Contrasted upper GI series (also known as an upper GI or as a barium oesophagram) is the key investigation.

Treatment depends on the patient's symptoms and the anatomical configuration of the hernia.

Uncomplicated sliding hiatal hernias are treated symptomatically with medical therapy, although some patients may select surgical therapy. Complicated hiatal hernias (those with bleeding, volvulus, or obstruction) have a stronger indication for surgical repair.

Complications include obstruction, bleeding, volvulus with and without strangulation or necrosis, and Barrett's oesophagus.

Definition

Hiatal hernia is the protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm. A hiatal hernia most commonly contains a variable portion of the stomach; less commonly, it may contain transverse colon, omentum, small bowel, or spleen, or some combination of these organs. 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

Full details

Other diagnostic factors

heartburn
regurgitation
obesity
chest pain
dysphagia
odynophagia
haematemesis
shortness of breath
cough
oropharyngitis
wheezing
non-bilious vomiting
fever and chills
confusion

Full details

Risk factors

obesity
previous gastro-oesophageal procedure
elevated intra-abdominal pressure
male gender
structural abnormalities of the oesophageal hiatus or the phreno-oesophageal ligaments
incisional, umbilical, or inguinal hernia
disorder of collagen metabolism
advanced age

Full details

Diagnostic investigations

1st investigations to order

CXR
upper GI series

Full details

Investigations to consider

OGD
CT scan or MRI scan
oesophageal manometry and pH monitoring

Full details

Treatment algorithm

INITIAL

Contributors

Authors VIEW ALL 

Constantine T. Frantzides, MD, PhD, FACS

Director

Chicago Institute of Minimally Invasive Surgery

Director of Minimally Invasive Surgery and Bariatric Fellowship Program

St. Francis Hospital

Chicago

Disclosures

CTF declares that he has no competing interests.

Minh B. Luu, MD, FACS

Surgery Residency Associate Director

Associate Professor

Rush University Medical Center

Chicago

Disclosures

MBL declares that he has no competing interests.

Acknowledgements

Dr Constantine T. Frantzides and Dr Minh B. Luu would like to gratefully acknowledge Dr Mark A. Carlson, a previous contributor to this monograph. MAC declares that he has no competing interests.

Peer reviewers VIEW ALL 

Frank A. Granderath, MD

Associate Professor

Department of General, Visceral and Transplant Surgery

University Hospital Tuebingen

Germany

Disclosures

FAG declares that he has no competing interests.

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Hiatal hernia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

upper GI haemorrhage and/or obstruction and/or volvulus

irreversible organ ischaemia and/or necrosis

symptomatic GORD

type I refractory to medical therapy or patient prefers surgery

types II, III, and IV

Contributors

Authors VIEW ALL 

Constantine T. Frantzides, MD, PhD, FACS

Disclosures

Minh B. Luu, MD, FACS

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Frank A. Granderath, MD

Disclosures

Differentials

Guidelines

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