Hiatal Hernia

A hiatal hernia is the protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. Hiatal hernias often result in heartburn but may also cause chest pain or pain with eating. The most common cause is obesity. The diagnosis is often made by endoscopy or medical imaging.

Types

Sliding Hernia

This is the most common type type of hiatal hernia and occurs when the connection between the esophagus and the stomach “slides” up above the diaphragm, often dragging part of the stomach with it into the chest.

Paraesophageal Hernias

A paraesophageal hiatal hernia occurs when a portion of the stomach protrudes through the hole by which the esophagus passes through the diaphragm. The hernia then lies alongside the esophagus. Paraesophageal hernias tend to gradually increase in size leading to the protrusion of other abdominal organs into the chest.

Diagnosis

Because the hiatal hernia protrudes into the chest rather than abdominal wall, there is no visible bulge as with an abdominal hernia. Diagnosis of a hiatal hernia requires upper GI endoscopy, a barium swallow study, an MRI, or computerized tomography (CT) scan.

Symptoms

The most common symptom of hiatal hernia is reflux of gastric (stomach) contents into the esophagus, which can lead to chronic heartburn, one of the underlying causes of gastroesophageal reflux disease (GERD). In addition to heartburn and difficulty swallowing, some severe forms of hiatal hernia can lead to restricted blood flow to the stomach, a surgical emergency.

Treatment

For some patients, hiatal hernias are asymptomatic and require no treatment. Sliding hiatal hernias presenting with symptoms of GERD symptoms are typically treated with medications such as antacids, histamine-2 blockers and proton pump inhibitors (PPIs). For others, surgical repair may be indicated.

Surgery

For paraesophageal hernias and very large sliding hernias, surgical repair may be needed. Various minimally invasive techniques, notably a Nissen Fundoplication, are used to successfully treat these conditions.