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Hiatus hernia

Hiatus hernias occur when there is herniation of abdominal contents through the oesophageal hiatus of the diaphragm into the thoracic cavity.

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

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.

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 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

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:

In the setting of trauma consider diaphragmatic rupture.

Article information

rID: 1447
Synonyms or Alternate Spellings:
  • Hiatal herniation
  • Hiatus hernias (HH)
  • Hiatal hernia
  • Hiatal hernias
  • Hiatal herniae
  • Hiatus herniae

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Cases and figures

  • Case 1: mixed-type hiatal hernia
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  • Case 2: sliding type
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  • Case 3
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  • Case 4
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  • Case 5: rolling type
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  • Paraesophageal hi...
    Case 6: para-oesophageal
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  • Case 7: sliding type
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  • Case 8: para-oesophageal
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  • Case 9: sliding type
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  • Case 10
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  • Case 11
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  • Case 12
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  • Case 13
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  •  Case 14: sliding type
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  • Case 15: para-oesophageal with gastric volvulus
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  •  Case 16
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  • Case 17
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  • Case 18: para-oesophageal
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  • Case 19
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  • Incidental hiatus...
    Case 20
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  • Case 21
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  • Case 22
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