The prevalence of hiatus hernia increases with age, with a slight female predilection.
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.
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: para-oesophageal hiatal hernia with the gastro-oesophageal junction in a normal position
- type 3: mixed or compound type, para-oesophageal hiatal hernia with displaced gastro-oesophageal junction
- type 4: mixed or compound type hiatal hernia with additional herniation of viscera
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).
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 (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.
Mixed rolling and sliding hiatus hernia
The mixed or compound hiatus 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. Large para-oesophageal hernias, with most of the stomach in the thorax, increases the risk for complications such as volvulus, obstruction, and ischaemia 6.
- retrocardiac opacity with air-fluid level
- numerous coarse thick gastric folds within the suprahiatal pouch
- tortuous oesophagus with an eccentric gastro-oesophageal junction
- 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
- para-oesophageal 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.
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.
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.
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- 2. Abbara S, Kalan MM, Lewicki AM. Intrathoracic stomach revisited. AJR Am J Roentgenol. 2003;181 (2): 403-14. AJR Am J Roentgenol (full text) - Pubmed citation
- 3. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22 (4): 601-16. doi:10.1016/j.bpg.2007.12.007 - Free text at pubmed - Pubmed citation
- 4. Govoni A, Whalen J, Kazam E. RadioGraphics. 1983;3 (4): . doi:10.1148/radiographics.3.4.612
- 5. Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Stefanidis D, Fanelli RD. Guidelines for the management of hiatal hernia. (2013) Surgical endoscopy. 27 (12): 4409-28. doi:10.1007/s00464-013-3173-3 - Pubmed
- 6. Jeffrey Klein, Emily N. Vinson, Clyde A. Helms, William E. Brant. Brant and Helms' Fundamentals of Diagnostic Radiology. (2018) ISBN: 9781496367396