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):
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/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.
HH containing stomach may result in gastric volvulus, which in turn presents as intestinal obstruction and may result in ischaemia/infarction.
- 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:
- 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.
- 1. Brant WE, Helms CA. Fundamentals of diagnostic radiology. Lippincott Williams & Wilkins. (2007) ISBN:0781765188. Read it at Google Books - Find it at Amazon
- 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