Hiatus hernia
Updates to Article Attributes
Hiatus hernias (alternative plural: herniae) occur when there is herniation of abdominal contents through the oesophageal hiatus of the diaphragm into the thoracic cavity.
Epidemiology
The prevalence of hiatus hernia increases with age, with a slight female predilection.
Clinical presentation
Many patients with hiatus hernia 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 content of a hiatus hernia is the stomach. There are two main types of hiatus hernia (although they may co-exist):
Some divide them into four types:
- type 1: sliding hiatal hernia (~95%)
- type 2: paraoesophageal hiatal hernia with the gastro-oesophageal junction in a normal position
- type 3: mixed or compound type, paraoesophageal hiatal hernia with displaced gastro-oesophageal junction
- type 4: mixed or compound type hiatal hernia with additional herniation of viscera
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). Under fluoroscopy, if >3 gastric folds are seen above the hiatus, this is suggestive of a sliding hiatus hernia.
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 (paraoesophageal) hiatus hernia
The rolling (paraoesophageal) 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.
Mixed rolling and sliding hiatus hernia
The mixed or compound hiatus hernia is the most common type of paraoesophageal hernia. The GOJ is displaced into the thorax with a large portion of the stomach, which is usually abnormally rotated. Large paraesophagealparaoesophageal hernias, with most of the stomach in the thorax, increase the risk for complications such as volvulus, obstruction, and ischemiaischaemia 6.
Radiographic features
Plain radiograph
- retrocardiac opacity with gas-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 phrenico-oesophageal ligament
- may see an increase in the fat surrounding the distal oesophagus
-
paraesophagealparaoesophageal hernia through a 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
Treatment and prognosis
Symptomatic hiatus hernias, especially types 2-4, should be managed surgically 5.
Complications
- a hiatus hernia containing the stomach may result in a gastric volvulus, which in turn presents as intestinal obstruction and may result in ischaemia/infarction, or very rarely a tension gastrothorax, causing respiratory failure and eventual cardiac arrest
- Cameron lesions: erosions in the setting of a large hiatus hernia
Differential diagnosis
On a frontal chest radiograph consider:
- retrocardiac lung abscess
- retrocardiac empyema
- epiphrenic oesophageal (pulsion) diverticulum
- phrenic ampulla
- postoperative change: oesophagectomy with gastric pull-up procedure
In the setting of trauma consider diaphragmatic rupture.
See also
-</ul><h5>Subtypes</h5><h6>Sliding hiatus hernia</h6><p>This is the most common type of hiatus hernia (~90%). The <a href="/articles/gastro-oesophageal-junction">gastro-oesophageal junction (GOJ)</a> 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). Under fluoroscopy, if >3 gastric folds are seen above the hiatus, this is suggestive of a sliding hiatus hernia.</p><p>The gastric fundus may also be displaced above the <a href="/articles/diaphragm">diaphragm</a> and present as a <a href="/articles/retrocardiac-mass">retrocardiac mass</a> on a chest radiograph. The presence of an air-fluid level in the mass suggests the diagnosis.</p><p>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 <a href="/articles/gastro-oesophageal-reflux-disease">gastro-oesophageal reflux</a> are the crucial factors in producing symptoms and causing complications.</p><h6>Rolling (paraoesophageal) hiatus hernia</h6><p>The rolling (paraoesophageal) 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.</p><h6>Mixed rolling and sliding hiatus hernia</h6><p>The mixed or compound hiatus hernia is the most common type of paraoesophageal hernia. The GOJ is displaced into the thorax with a large portion of the stomach, which is usually abnormally rotated. Large paraesophageal hernias, with most of the stomach in the thorax, increase the risk for complications such as volvulus, obstruction, and ischemia <sup>6</sup>. </p><h4>Radiographic features</h4><h5>Plain radiograph</h5><ul><li>retrocardiac opacity with gas-fluid level</li></ul><h5>Fluoroscopy</h5><ul>- +</ul><h5>Subtypes</h5><h6>Sliding hiatus hernia</h6><p>This is the most common type of hiatus hernia (~90%). The <a href="/articles/gastro-oesophageal-junction">gastro-oesophageal junction (GOJ)</a> 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). Under fluoroscopy, if >3 gastric folds are seen above the hiatus, this is suggestive of a sliding hiatus hernia.</p><p>The gastric fundus may also be displaced above the <a href="/articles/diaphragm">diaphragm</a> and present as a <a href="/articles/retrocardiac-mass">retrocardiac mass</a> on a chest radiograph. The presence of an air-fluid level in the mass suggests the diagnosis.</p><p>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 <a href="/articles/gastro-oesophageal-reflux-disease">gastro-oesophageal reflux</a> are the crucial factors in producing symptoms and causing complications.</p><h6>Rolling (paraoesophageal) hiatus hernia</h6><p>The rolling (paraoesophageal) 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.</p><h6>Mixed rolling and sliding hiatus hernia</h6><p>The mixed or compound hiatus hernia is the most common type of paraoesophageal hernia. The GOJ is displaced into the thorax with a large portion of the stomach, which is usually abnormally rotated. Large paraoesophageal hernias, with most of the stomach in the thorax, increase the risk for complications such as volvulus, obstruction, and ischaemia <sup>6</sup>. </p><h4>Radiographic features</h4><h5>Plain radiograph</h5><ul><li>retrocardiac opacity with gas-fluid level</li></ul><h5>Fluoroscopy</h5><ul>
-<li>paraesophageal hernia through a widened oesophageal hiatus<ul>- +<li>paraoesophageal hernia through a widened oesophageal hiatus<ul>
Image 24 MRI (Gradient Echo) ( create )
Unable to process the form. Check for errors and try again.