• Clinical science

Hiatal hernia

Abstract

A hiatal (or hiatus) hernia is the abnormal protrusion of any abdominal structure/organ, most often a portion of the stomach, into the thoracic cavity through a lax diaphragmatic esophageal hiatus. It may be congenital or secondary to ageing, obesity, and/or smoking. There are four types of hiatal hernia: sliding, paraesophageal, mixed, and complex. Sliding hiatal hernias, where the gastroesophageal junction (GEJ) and the gastric cardia migrate into the thorax, account for 95% of hiatal hernias. In paraesophageal hernias (PEH), only the gastric fundus herniates into the thorax, whereas in mixed hiatal hernias, the GEJ as well as the gastric fundus herniate. Complex hiatal hernias are rare and characterized by protrusion of any abdominal organ other than the stomach. Nearly half of all patients with hiatal hernia are asymptomatic and require no medical or surgical intervention. Symptomatic patients with sliding hiatal hernia present with features of gastroesophageal reflux disease (GERD), which are usually managed with lifestyle modification and proton pump inhibitors. Patients with PEH or mixed hiatal hernias typically present with intermittent dysphagia, substernal discomfort, or abdominal pain, and in rare cases present acutely with gastric volvulus and strangulation. All symptomatic PEH, mixed, and complex hiatal hernias require operative intervention to avoid life-threatening complications.

Definition

Protrusion of any abdominal structure/organ into the thorax through a lax diaphragmatic esophageal hiatus. (In 95% of cases, a portion of the stomach is herniated.)

Epidemiology

  • Incidence increases with:
    • Age: affects ∼ 70% of people > 70 years
    • BMI
  • Prevalence: more prevalent in females and Western populations[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

  • The etiology is multifactorial. [1]
    • Lax diaphragmatic esophageal hiatus
      • Advanced age: The phrenoesophageal ligament weakens with increasing age.
      • Smoking: causes a loss of elastin fibres in the diaphragmatic crura
      • Obesity: The deposition of fat in and around the crura widens the hiatus.
      • Genetic predisposition (rare)[3]
    • Prolonged periods of increased intra-abdominal pressure

Classification

Types of hiatal hernias[3]

Type I: Sliding hiatal hernia

Type II: Paraesophageal hiatal hernia

Type III: Mixed hiatal hernia

  • Mix of types I and II
  • The GEJ and a portion of the gastric fundus prolapse through the hiatus.

Type IV: Complex hiatal hernia

  • Herniation of any abdominal structure other than the stomach (e.g., spleen, omentum, or colon)
  • Rarest type

Pathophysiology

Anatomy[1]

  • Esophageal hiatus: central opening of the diaphragm, which allows the esophagus to pass through into the peritoneal cavity; forms the upper part of the esophageal sphincter and the reflux barrier
    • Formed by:
      • Left and right paravertebral tendinous crura
      • Median arcuate ligament[4]
  • Gastroesophageal junction (GEJ): normally lies at the level of the esophageal hiatus
    • Phrenoesophageal ligament (PEL) attaches to the esophagus at the GEJ: closes the esophageal hiatus and helps maintain the intra-abdominal position of the GEJ

Changes in the presence of a hiatal hernia

  • Predisposing factors lead to laxity of the esophageal hiatus, e.g.:[1]
    • Advanced age → phrenoesophageal ligament weakens
    • Smoking → loss of elastin fibres in the diaphragmatic crura
    • Obesity → deposition of fat in and around the crura → widened hiatus
  • Relative negative intrathoracic pressure + the lax hiatus → herniation of the abdominal contents into the thorax → loss of reflux barrier + compromised fluid emptying of distal esophagusgastroesophageal reflux disease (GERD); ; ; [4][1][6]

Clinical features

  • Most patients are asymptomatic
  • Type I: symptoms of GERD[4]
  • Type II, III, and IV:[4]
    • Epigastric/substernal pain
    • Early satiety
    • Retching
    • Symptoms of GERD can occur.
  • Saint's triad: A combination of cholelithiasis, diverticulosis, and hiatal hernia may occur in ∼ 1.5% of patients. [7]

Diagnostics

  • Barium swallow: most sensitive test
    • Assesses type and size of a hernia (including location of the stomach and the GEJ)[4][1] (see “Classification” above)
  • Endoscopy: used to diagnose hiatal hernia and evaluate for possible complications (see “Complications” below)
    • Z-line: squamocolumnar junction, which represents the transition from the squamous epithelium-lined esophageal mucosa to the columnar epithelium-lined gastric mucosa; corresponds to the GEJ[4][1]
      • Types I and III: Z-line lies above the diaphragmatic hiatus
      • Types II and IV: Z-line remains undisplaced (below the diaphragmatic hiatus)

  • Other tests that can detect hiatal hernias include:[3]
    • Chest x-ray
      • Usually incidental finding[1]
      • Types I, II, III: Retrocardiac soft tissue opacity with/without an air-fluid level
      • Type IV: Retrocardiac visceral gas (small bowel/colon) or soft tissue shadows (spleen/omentum)
    • CT Thorax: Recommended for urgent preoperative evaluation of complicated type II, III, and IV hernias
    • Esophageal manometry: Helps calculate the size of a sliding hiatal hernia by accurately identifying the level of the diaphragmatic hiatus
    • Esophageal pH monitoring: Not a diagnostic test; useful for determining the extent of gastroesophageal reflux

.

  • Endoscopic ultrasound and Transesophageal ECHO can also detect Hiatal hernias but are not commonly used modalities for diagnosis

Treatment

Management of patients with sliding hiatal hernia[1]

Management of patients with types II, III, IV hiatal hernias[3]

  • Conservative management: older patients or those with other comorbidities
  • Surgery: laparoscopic/open herniotomy + fundoplication, hiatoplasty, and gastropexy/fundopexy
    • Indications
      • Asymptomatic, small hernias in patients < 50 years of age
      • Symptomatic type II, III, IV hernias

Complications

Complications of type I[4]

Complications of type II, III, IV[4]

The complications of types II, III, and IV are often medical emergencies!

We list the most important complications. The selection is not exhaustive.

  • 1. Qureshi WA. Hiatal Hernia. In: Katz J. Hiatal Hernia. New York, NY: WebMD. http://emedicine.medscape.com/article/178393. Updated January 3, 2016. Accessed January 13, 2017.
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  • 3. Kohn GP, Price RR, Demeester SR et al. Guidelines for the Management of Hiatal Hernia. https://www.sages.org/publications/guidelines/guidelines-for-the-management-of-hiatal-hernia. Updated April 1, 2013. Accessed January 12, 2017.
  • 4. Kahrilas PJ. Hiatus hernia. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/hiatus-hernia. Last updated July 25, 2016. Accessed January 13, 2017.
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  • 7. Hauer-jensen M, Bursac Z, Read RC. Is herniosis the single etiology of Saint's triad?. Hernia. Hernia. 2009; 13(1): pp. 29–34. doi: 10.1007/s10029-008-0421-x.
  • 8. Weston AP. Hiatal hernia with cameron ulcers and erosions. Gastrointest Endosc Clin N Am. 1996; 6(4): pp. 671–679. pmid: 8899401.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
  • Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation?. Ann Surg. 2002; 236(4): pp. 492–500. url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1422604/.
last updated 02/20/2018
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