Hiatus hernia

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

The prevalence of HH increases with age, with a slight female predilection.

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 HH are considered synonymous with gastro-oesophageal reflux disease (GORD) but there is a poor correlation between the two conditions.

The most common contents of a HH 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. 

Plain radiograph
  • retrocardiac opacity with air-fluid level
  • focal fat collection in middle mediastinum
    • omentum herniates through phrenicoesophageal ligament
    • may see increase in fat surrounding distal oesophagus
  • paraesophageal hernia through widened oesophageal hiatus
    • visualise contents, size, orientation of herniated stomach within lower thorax
    • herniated contents lie adjacent to oesophagus
  • widening of oesophageal hiatus
    • dehiscence of diaphragmatic crura (>15 mm): increased distance between crura and oesophageal wall

On a frontal chest radiograph consider:

In the setting of trauma consider diaphragmatic rupture.

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Article Information

rID: 1447
Section: Pathology
Synonyms or Alternate Spellings:
  • Hiatal herniation
  • Hiatus hernias (HH)

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