Hiatus hernia
Updates to Article Attributes
Hiatus hernias ) occur when there is herniation of abdominal contents through the oesophageal hiatus of the diaphragm into the thoracic cavity.
Epidemiology
The prevalence of HH increases with age, with a slight female predilection.
Clinical presentation
Many patients with HH are asymptomatic, and it is an incidental finding. However, symptoms may include epigastric or chest pain, postprandial fullness, nausea and vomiting 3.
Sometimes hiatus hernias are considered synonymous with gastro-oesophageal reflux disease (GORD), but there is a poor correlation between the two conditions.
Pathology
The most common contents of a hiatus hernia is the stomach. There are two main types of hiatus hernia (although they may co-exist):
Subtypes
Sliding hiatus hernia
This is the most common type of hiatus hernia (~90%). The gastro-oesophageal junction (GOJ) is usually displaced >2 cm above the oesophageal hiatus. The oesophageal hiatus is often abnormally widened to 3-4 cm (the upper limit of normal is 1.5 cm).
The gastric fundus may also be displaced above the diaphragm and present as a retrocardiac mass on a chest radiograph. The presence of an air-fluid level in the mass suggests the diagnosis.
Small, sliding hiatus hernias commonly reduce in the upright position. The mere presence of a sliding hiatus hernia is of limited clinical significance in most cases. The function of the lower oesophageal sphincter and the presence of pathologic gastro-oesophageal reflux are the crucial factors in producing symptoms and causing complications.
Rolling/Sliding (para-oesophageal) hiatus hernia
The rolling (para-oesophageal) hiatus hernia is much less common than the sliding type. The GOJ remains in its normal location while a portion of the stomach herniates above the diaphragm.
The mixed or compound hiatal hernia is the most common type of para-oesophageal hernia. The GOJ is displaced into the thorax with a large portion of the stomach, which is usually abnormally rotated.
Complications
HH containing stomach may result in gastric volvulus, which in turn presents as intestinal obstruction and may result in ischaemia/infarction.
Radiographic features
Plain radiograph
- retrocardiac opacity with air-fluid level
Fluoroscopy
- numerous coarse thick gastric folds within the suprahiatal pouch
- tortuous oesophagus with an eccentric gastro-oesophageal junction
CT
- focal fat collection in the middle mediastinum
- omentum herniates through the phrenicoesophageal ligament
- may see an increase in the fat surrounding distal oesophagus
- paraesophageal hernia through widened oesophageal hiatus
- visualise contents, size, orientation of herniated stomach within the lower thorax
- herniated contents lie adjacent to the oesophagus
- widening of oesophageal hiatus
- dehiscence of diaphragmatic crura (>15 mm): increased distance between crura and oesophageal wall
Differential diagnosis
On a frontal chest radiograph consider:
- retrocardiac lung abscess
- retrocardiac empyema
- epiphrenic oesophageal (pulsion) diverticulum
- phrenic ampulla
- post-operative change: oesophagectomy with gastric pull-up procedure
In the setting of trauma consider diaphragmatic rupture.
See also
-<p><strong>Hiatus hernias </strong>) occur when there is herniation of abdominal contents through the <a href="/articles/oesophageal-hiatus">oesophageal hiatus</a> of the <a href="/articles/diaphragm">diaphragm</a> into the thoracic cavity.</p><h4>Epidemiology</h4><p>The prevalence of HH increases with age, with a slight female predilection.</p><h4>Clinical presentation</h4><p>Many patients with HH are asymptomatic, and it is an incidental finding. However, symptoms may include epigastric or chest pain, postprandial fullness, nausea and vomiting <sup>3</sup>. </p><p>Sometimes hiatus hernias are considered synonymous with <a href="/articles/gastro-oesophageal-reflux-disease">gastro-oesophageal reflux disease (GORD)</a>, but there is a poor correlation between the two conditions.</p><h4>Pathology</h4><p>The most common contents of a hiatus hernia is the <a href="/articles/stomach">stomach</a>. There are two main types of hiatus hernia (although they may co-exist):</p><ul>- +<p><strong>Hiatus hernias </strong>occur when there is herniation of abdominal contents through the <a href="/articles/oesophageal-hiatus">oesophageal hiatus</a> of the <a href="/articles/diaphragm">diaphragm</a> into the thoracic cavity.</p><h4>Epidemiology</h4><p>The prevalence of HH increases with age, with a slight female predilection.</p><h4>Clinical presentation</h4><p>Many patients with HH are asymptomatic, and it is an incidental finding. However, symptoms may include epigastric or chest pain, postprandial fullness, nausea and vomiting <sup>3</sup>. </p><p>Sometimes hiatus hernias are considered synonymous with <a href="/articles/gastro-oesophageal-reflux-disease">gastro-oesophageal reflux disease (GORD)</a>, but there is a poor correlation between the two conditions.</p><h4>Pathology</h4><p>The most common contents of a hiatus hernia is the <a href="/articles/stomach">stomach</a>. There are two main types of hiatus hernia (although they may co-exist):</p><ul>
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