Hiatus Hernia


A hiatus hernia (hiatal hernia; diaphragmatic hernia) occurs when part of your stomach pushes upward through your diaphragm into the chest. Your diaphragm normally has a small opening (hiatus) through which your food tube (oesophagus) passes on its way to connect to your stomach. The stomach can push up through this opening and cause a hiatus hernia.

In most cases, a small hiatal hernia doesn’t cause problems, and you may never know you have a hiatus hernia unless your doctor discovers it when checking for another condition during gastroscopy (endoscopy) or barium swallow. But a large hiatus hernia can allow food and acid to back up into your oesophagus, leading to heartburn. Self-care measures or medications can usually relieve these symptoms, although a very large hiatus hernia sometimes requires surgery.

Types of Hiatus Hernias

The current anatomic classification has evolved to include a categorization of hiatus hernias into Types I – IV.

Type I hernias are sliding hiatus hernias, where the gastroesophageal junction migrates above the diaphragm. The stomach remains in its usual longitudinal alignment and the fundus remains below the gastroesophageal junction.

Type II hernias are pure paraesophageal hernias (PEH); the gastroesophageal junction remains in its normal anatomic position but a portion of the fundus herniates through the diaphragmatic hiatus adjacent to the oesophagus.

Type III hernias are a combination of Types I and II, with both the gastroesophageal junction and the fundus herniating through the hiatus. The fundus lies above the gastroesophageal junction.

Type IV hernias are characterised by the presence of a structure other than stomach, such as the omentum, colon or small bowel within the hernia sac.

Greater than 95% of hiatus hernias are Type I. Types II – IV hernias as a group are referred to as paraesophageal hernias (PEH), and are differentiated from Type I hernias by relative preservation of posterolateral phrenoesophageal attachments around the gastroesophageal junction.


The mainstays of evaluation for patients with a hiatus hernia, particularly prior to operative intervention, are upper endoscopy i.e gastroscopy and barium swallow. Contrast studies are reported to be more sensitive than endoscopy in detecting sliding hiatus hernia, at least in the bariatric population. The role of the various diagnostic techniques may depend on the clinical presentation of the patient.

Impedance pH & High Resolution Manometry can demonstrate the level of the diaphragmatic crura, the respiratory inversion point and the location of the lower oesophageal sphincter. The size of the sliding component of a hiatus hernia can then be calculated, particularly with new high resolution motility technology. In patients with a paraoesophageal hiatus hernia placement of the manometry catheter across the lower oesophageal sphincter and below the diaphragm can be difficult . An oesophageal motility study is critical to enable a pH probe to be properly positioned above the lower esophageal sphincter in patients with a sliding hiatus hernia and symptoms of gastroesophageal reflux.

pH testing has limited relevance in the diagnosis of a hiatus hernia, but is critical to identify the presence of increased esophageal acid exposure in patients with sliding hiatus hernias that might benefit from antireflux surgery. Confirmation of abnormal gastroesophageal reflux either by the identification of erosive esophagitis or Barrett’s esophagus on upper endoscopy, or by demonstration of increased oesophageal acid exposure on pH monitoring is necessary prior to consideration of operative intervention in patients with a sliding hiatus hernia.

Signs and Symptoms

Most people with hiatus hernias are asymptomatic. In a minority of individuals, hiataus hernias may predispose to reflux or worsen existing reflux.


Complications of hiatus hernia may include the following:

  • Intermittent bleeding from associated esophagitis, erosions (Cameron ulcers), or a discrete oesophageal ulcer, leading to iron-deficiency anaemia
  • Incarcerated hiatus hernia (rare; observed only with paraesophageal hernia)

How do hiatus hernia occur?

Your diaphragm is a large dome-shaped muscle that separates your chest cavity from your abdomen. Normally, your oesophagus passes into your stomach through an opening in the diaphragm called the hiatus. Hiatus hernias occur when the muscle tissue surrounding this opening becomes weak, and the upper part of your stomach bulges up through the diaphragm into your chest cavity

Certain conditions may predispose to the development of hiatus hernia, including the following:

  • Muscle weakening and loss of elasticity with age
  • Pregnancy
  • Obesity
  • Abdominal ascites
  • Older age (≥ 50 yrs)

Diaphragmatic hernias may be congenital or acquired. Acquired hiatal hernias are divided further into non-traumatic (more common) and traumatic hernias.


Most people with Hiatus hernia don’t experience any signs or symptoms and won’t need treatment. If you experience signs and symptoms, such as recurrent heartburn and acid reflux, you may require treatment, which can include medications or surgery.

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