A hiatal hernia or hiatus hernia is a type of

hernia A hernia (: hernias or herniae, from Latin, meaning 'rupture') is the abnormal exit of tissue or an organ (anatomy), organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal Devel ...

in which

abdominal The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...

organs In a multicellular organism, an organ is a collection of tissues joined in a structural unit to serve a common function. In the hierarchy of life, an organ lies between tissue and an organ system. Tissues are formed from same type cells to a ...

(typically the

stomach The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...

) slip through the

diaphragm Diaphragm may refer to: Anatomy * Thoracic diaphragm, a thin sheet of muscle between the thorax and the abdomen * Pelvic diaphragm or pelvic floor, a pelvic structure * Urogenital diaphragm or triangular ligament, a pelvic structure Other * Diap ...

into the middle compartment of the chest. This may result in

gastroesophageal reflux disease Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or ...

(GERD) or

laryngopharyngeal reflux Laryngopharyngeal reflux (LPR) or laryngopharyngeal reflux disease (LPRD) is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respiratory symptoms such as cough and wheezing and is often asso ...

(LPR) with symptoms such as a taste of acid in the back of the mouth or

heartburn Heartburn is a burning sensation felt behind the breastbone. It is a symptom that is commonly linked to acid reflux and is often triggered by food, particularly fatty, sugary, spicy, chocolate, citrus, onion-based and tomato-based products. Ly ...

. Other symptoms may include

trouble swallowing Dysphagia is difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, in some contexts it is classified as a disease#Terminology, condition in its own right. It may be a sensation that suggests difficulty in the pass ...

and

chest pain Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...

s. Complications may include

iron deficiency anemia Iron-deficiency anemia is anemia caused by a lack of iron. Anemia is defined as a decrease in the number of red blood cells or the amount of hemoglobin in the blood. When onset is slow, symptoms are often vague such as feeling tired, weak, sh ...

volvulus A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symp ...

, or

bowel obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or Ileus, functional obstruction of the Gastrointestinal tract#Lower gastrointestinal tract, intestines which prevents the normal movement of the products of digestion. Ei ...

. The most common risk factors are

obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

and older age. Other risk factors include

major trauma Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Dependi ...

scoliosis Scoliosis (: scolioses) is a condition in which a person's Vertebral column, spine has an irregular curve in the coronal plane. The curve is usually S- or C-shaped over three dimensions. In some, the degree of curve is stable, while in others ...

, and certain types of surgery. There are two main types: sliding hernia, in which the body of the stomach moves up; and paraesophageal hernia, in which an abdominal organ moves beside the

esophagus The esophagus (American English), oesophagus (British English), or œsophagus (Œ, archaic spelling) (American and British English spelling differences#ae and oe, see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), c ...

. The diagnosis may be confirmed with

endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...

. Endoscopy is typically only required when concerning symptoms are present, symptoms are resistant to treatment, or the person is over 50 years of age. Symptoms from a hiatal hernia may be improved by changes such as raising the head of the bed, weight loss, and adjusting eating habits. Medications that reduce

gastric acid Gastric acid or stomach acid is the acidic component – hydrochloric acid – of gastric juice, produced by parietal cells in the gastric glands of the stomach lining. In humans, the pH is between one and three, much lower than most other a ...

such as

H2 blockers H2 antagonists, sometimes referred to as H2RAs and also called H2 blockers, are a class of medications that block the action of histamine at the histamine H2 receptors of the parietal cells in the stomach. This decreases the production of stomac ...

proton pump inhibitor Proton-pump inhibitors (PPIs) are a class of medications that cause a profound and prolonged reduction of stomach acid production. They do so by irreversibly inhibiting the stomach's H+/K+ ATPase proton pump. The body eventually synthesizes ne ...

s may also help with the symptoms. If the condition does not improve with medications, a

surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

to carry out a laparoscopic fundoplication may be an option. Between 10% and 80% of adults in North America are affected.

Signs and symptoms

Hiatal hernia has often been called the "great mimic" because its symptoms can resemble many disorders. Among them, a person with a hiatal hernia can experience dull pains in the chest,

shortness of breath Shortness of breath (SOB), known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that con ...

(caused by the hernia's effect on the

heart palpitations Palpitations occur when a person becomes aware of their heartbeat. The heartbeat may feel hard, fast, or uneven in their chest. Symptoms include a very fast or irregular heartbeat. Palpitations are a sensory symptom. They are often described as ...

(due to irritation of the

vagus nerve The vagus nerve, also known as the tenth cranial nerve (CN X), plays a crucial role in the autonomic nervous system, which is responsible for regulating involuntary functions within the human body. This nerve carries both sensory and motor fibe ...

), and swallowed food "balling up" and causing discomfort in the lower esophagus until it passes on to the stomach. In addition, hiatal hernias often result in

but may also cause chest pain or pain with eating. In most cases, however, a hiatal hernia does not cause any symptoms. The pain and discomfort that a patient experiences are due to the reflux of gastric acid, air, or bile. While there are several causes of

acid reflux Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or ...

, it occurs more frequently in the presence of a hiatal hernia. In newborns, the presence of

Bochdalek hernia Bochdalek hernia is one of two forms of a congenital diaphragmatic hernia, the other form being Morgagni hernia. A Bochdalek hernia is a congenital abnormality in which an opening exists in the infant's diaphragm, allowing normally intra-abdomin ...

can be recognised from symptoms such as difficulty breathing, fast respiration, and increased heart rate.

Causes

The following are potential causes of a hiatal hernia. * Increased pressure within the

abdomen The abdomen (colloquially called the gut, belly, tummy, midriff, tucky, or stomach) is the front part of the torso between the thorax (chest) and pelvis in humans and in other vertebrates. The area occupied by the abdomen is called the abdominal ...

caused by: ** Heavy lifting or bending over ** Frequent or hard

coughing A cough is a sudden expulsion of air through the large breathing passages which can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three ...

** Hard sneezing ** Violent vomiting ** Straining during

defecation Defecation (or defaecation) follows digestion and is the necessary biological process by which organisms eliminate a solid, semisolid, or liquid metabolic waste, waste material known as feces (or faeces) from the digestive tract via the anus o ...

(i.e., the

Valsalva maneuver The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air, as if blowing up a balloon. Variations of the maneuver can be ...

)

Obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

and age-related changes to the diaphragm are also general risk factors.

Diagnosis

The diagnosis of a hiatal hernia is typically made through an

upper GI series An upper gastrointestinal series, also called a barium swallow, barium study, or barium meal, is a series of radiographs used to examine the gastrointestinal tract for abnormalities. A contrast medium, usually a radiocontrast agent such as barium ...

high resolution manometry High-resolution manometry (HRM) is a gastrointestinal motility diagnostic system that measures intraluminal pressure activity in the gastrointestinal tract using a series of closely spaced pressure sensors. For a manometry system to be classifie ...

esophageal pH monitoring In gastroenterology, esophageal pH monitoring is the current gold standard for diagnosis of gastroesophageal reflux disease (GERD). It provides direct physiologic measurement of acid in the esophagus and is the most objective method to document ...

, and

computed tomography A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

(CT). Barium swallow, as in the upper GI series, allows the size, location, stricture, and stenosis of oesophagus to be seen. It can also evaluate the oesophageal movements. Endoscopy can analyse the esophageal internal surface for erosions, ulcers, and tumours. Meanwhile, manometry can determine the integrity of esophageal movements and the presence of

esophageal achalasia Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esopha ...

. pH testing allows the quantitative analysis of acid reflux episodes. A CT scan is useful in diagnosing complications of hiatal hernia, such as gastric volvulus, perforation,

pneumoperitoneum Pneumoperitoneum is pneumatosis (abnormal presence of air or other gas) in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal organ, generally from a perforated peptic ulcer, alt ...

, and pneumomediastinum. File:HiatusHernia10.JPG, A large hiatal hernia on

chest X-ray A chest radiograph, chest X-ray (CXR), or chest film is a Projectional radiography, projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common fi ...

marked by open arrows in contrast to the heart borders marked by closed arrows File:Hiatus hernia with air-fluid level.jpg, This hiatal hernia is mainly identified by an air-fluid level (labeled with arrows). File:Hiatus-hernia.jpg, Upper GI endoscopy depicting hiatal hernia File:Type_1_hiatus_hernia_on_retroflexion_with_fundic_gland_polyps.jpg, Upper GI endoscopy in retroflexion showing Type I hiatal hernia File:Hiatus hernia on CT scan.jpg, A hiatal hernia as seen on CT File:HiatusHerniaMark.png, A large hiatal hernia as seen on CT imaging File:HiatusHerniaCorMark.png, A large hiatal hernia as seen on CT imaging File:UOTW 39 - Ultrasound of the Week 1.webm, As seen on ultrasound File:UOTW 39 - Ultrasound of the Week 2.webm, As seen on ultrasound

Classification

Four types of esophageal hiatal hernia are identified: Type I: A type I hernia, also known as a sliding hiatal hernia, occurs when part of the stomach slides up through the hiatal opening in the diaphragm. There is a widening of the muscular hiatal tunnel and circumferential laxity of the

phrenoesophageal ligament The phrenoesophageal ligament (phrenicoesophageal ligament, or phrenoesophageal membrane) is the ligament by which the esophagus is attached to the diaphragm. It is an extension of the inferior diaphragmatic fascia and is divided into an upper a ...

, allowing a portion of the gastric cardia to herniate upward into the posterior mediastinum. The clinical significance of type I hernias is in their association with reflux disease. Sliding hernias are the most common type and account for 95% of all hiatal hernias. (C) Type II: A type II hernia, also known as a paraesophageal or rolling hernia, occurs when the fundus and greater curvature of the stomach roll up through the diaphragm, forming a pocket alongside the esophagus. It results from a localized defect in the phrenoesophageal ligament while the gastroesophageal junction remains fixed to the preaortic fascia and the median arcuate ligament. The gastric fundus then serves as the leading point of herniation. Although type II hernias are associated with reflux disease, their primary clinical significance lies in the potential for mechanical complications. (D) Type III: Type III hernias have elements of both types I and II hernias. With progressive enlargement of the hernia through the hiatus, the phrenoesophageal ligament stretches, displacing the gastroesophageal junction above the diaphragm, thereby adding a sliding element to the type II hernia. Type IV: Type IV hiatus hernia is associated with a large defect in the phrenoesophageal ligament, allowing other organs, such as the colon, spleen, pancreas, and small intestine to enter the hernia sac. The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180° around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation, the abnormality is usually referred to as an intrathoracic stomach.

Treatment

In the great majority of cases, people experience no significant discomfort, and no treatment is required. People with symptoms should elevate the head of their beds and avoid lying down directly after meals. If the condition has been brought on by stress, stress reduction techniques may be prescribed, or if overweight,

weight loss Weight loss, in the context of medicine, health, or physical fitness, refers to a reduction of the total body mass, by a mean loss of fluid, body fat (adipose tissue), or lean mass (namely bone mineral deposits, muscle, tendon, and other conn ...

may be indicated.

Medications

Antisecretory drugs such as

proton pump inhibitors Proton-pump inhibitors (PPIs) are a class of medications that cause a profound and prolonged reduction of gastric acid, stomach acid production. They do so by irreversibly inhibiting the stomach's H+/K+ ATPase, H+/K+ ATPase proton pump. The body ...

and H₂ receptor blockers can be used to reduce acid secretion. Medications that reduce the

lower esophageal sphincter The esophagus (American English), oesophagus (British English), or œsophagus ( archaic spelling) ( see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), colloquially known also as the food pipe, food tube, or gullet, ...

(LES) pressure should be avoided.

Procedures

There is tentative evidence from non-controlled trials that oral neuromuscular training may improve symptoms. This has been approved by the UK

National Health Service The National Health Service (NHS) is the term for the publicly funded health care, publicly funded healthcare systems of the United Kingdom: the National Health Service (England), NHS Scotland, NHS Wales, and Health and Social Care (Northern ...

for supply on prescription from 1 May 2022.

Surgery

In some unusual instances, as when the hiatal hernia is unusually large, or is of the paraesophageal type, it may cause

esophageal stricture A benign esophageal stricture, or peptic stricture, is a narrowing or tightening of the esophagus that causes swallowing difficulties. Signs and symptoms Symptoms of esophageal strictures include heartburn, bitter or acid taste in the mouth, cho ...

or severe discomfort. About 5% of hiatal hernias are paraesophageal. If symptoms from such a hernia are severe, for example, if chronic acid reflux threatens to severely injure the

or is causing

Barrett's esophagus Barrett's esophagus is a condition in which there is an abnormal ( metaplastic) change in the mucosal cells that line the lower part of the esophagus. The cells change from stratified squamous epithelium to simple columnar epithelium, intersper ...

is sometimes recommended. However, surgery has its risks, including death and disability, so that even for large or paraesophageal hernias, watchful waiting may, on balance, be safer and cause fewer problems than surgery. Complications from surgical procedures to correct a hiatal hernia may include

gas bloat syndrome A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical thera ...

dysphagia Dysphagia is difficulty in swallowing. Although classified under " symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right. It may be a sensation that suggests difficulty in the passage of solids or l ...

(trouble swallowing),

dumping syndrome Dumping syndrome occurs when food, especially sugar, moves too quickly from the stomach to the duodenum—the first part of the small intestine—in the upper gastrointestinal (GI) tract. This condition is also called rapid gastric emptying. It i ...

, excessive scarring, and rarely,

achalasia Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esopha ...

. Surgical procedures sometimes fail over time, requiring a second surgery to make repairs. One surgical procedure used is called

Nissen fundoplication A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical thera ...

. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of

. The procedure is now commonly performed

laparoscopically Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...

. With proper patient selection, laparoscopic

fundoplication A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical thera ...

studies in the 21st century have indicated relatively low complication rates, quick recovery, and relatively good long-term results. Regarding the discussion of partial versus complete fundoplication procedures, significant variations in the postoperative outcome emphasize the increased prevalence of dysphagia after Nissen. The statistics support the superiority of laparoscopic over traditional surgery, owing to the greater aesthetic result, shorter admission time, lower costs, and faster social reintegration.

Epidemiology

The incidence of hiatal hernia increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia. Of these, 9% are symptomatic, depending on the competence of the

(LES). 95% of these are "sliding" hiatal hernias, in which the LES protrudes above the diaphragm along with the stomach, and only 5% are the "rolling" type (paraesophageal), in which the LES remains stationary, but the stomach protrudes above the diaphragm. Hiatal hernias are most common in North America and Western Europe and rare in rural African communities. Some have proposed that insufficient dietary fiber and the use of a high sitting position for defecation may increase the risk.

Veterinary

Hiatal hernia has been described in small animals since 1974, with the first case being in two dogs. It has since been reported in cats, too. Type I is the most common, and Type II is also common, but Types III and IV are rare, with scarce reports in the literature. In dogs, it is estimated that 60% of cases are

congenital A birth defect is an abnormal condition that is present at childbirth, birth, regardless of its cause. Birth defects may result in disability, disabilities that may be physical disability, physical, intellectual disability, intellectual, or dev ...

with

brachycephalic Brachycephaly (derived from the Ancient Greek '' βραχύς'', 'short' and '' κεφαλή'', 'head') is the shape of a skull shorter than average in its species. It is perceived as a cosmetically desirable trait in some domesticated dog and ...

breeds being the most affected due to the

oesophageal hiatus In human anatomy, the esophageal hiatus is an opening in the diaphragm through which the esophagus and the vagus nerve pass. Structure The esophageal hiatus is an oval opening in (sources differ) the right crus of the diaphragm/left crus of the ...

' cross-sectional area being larger than normocephalic and doliocephalic dogs. The diaphragm failing to fuse during development of the

embryo An embryo ( ) is the initial stage of development for a multicellular organism. In organisms that reproduce sexually, embryonic development is the part of the life cycle that begins just after fertilization of the female egg cell by the male sp ...

is believed to be the cause of congenital hiatal hernia. The

Shar-pei The Shar Pei () is a dog breed from southern China. Traditionally kept as a property guardian, the shar pei was driven to the brink of extinction in the 20th century. The breed is known in the West for its deep wrinkles, while a traditional less w ...

and

Bulldog The Bulldog is a British breed of dog of mastiff type. It may also be known as the English Bulldog or British Bulldog. It is a stocky, muscular dog of medium size, with a large head, thick folds of skin around the face and shoulders and a rel ...

are most commonly affected, however, no mutation or heritability has been identified as of 2023. Other risk factors for the condition include: nasal masses,

laryngeal paralysis Laryngeal paralysis in animals is a condition in which the nerves and muscles that control the movements of one or both arytenoid cartilages of the larynx cease to function, and instead of opening during aspiration and closing during swallowing, th ...

, and a narrowed intrapharyngeal opening.

Tetanus Tetanus (), also known as lockjaw, is a bacterial infection caused by ''Clostridium tetani'' and characterized by muscle spasms. In the most common type, the spasms begin in the jaw and then progress to the rest of the body. Each spasm usually l ...

has been identified as a cause in dogs; these cases can be resolved via treating the tetanus. Treatment of airway obstructions and feeding low-fat, more digestible food can alleviate any need for invasive procedures.

References

External links

{{DEFAULTSORT:Hiatus Hernia Congenital disorders of digestive system Diaphragmatic hernias Wikipedia emergency medicine articles ready to translate Wikipedia medicine articles ready to translate