A 45-year-old man presented with chest pain, difficulty swallowing, and heartburn after meals, especially when reclining. Imaging showed a hiatal hernia, which is a herniation of the stomach through the diaphragm into the chest cavity. The two main types are sliding and paraesophageal hernias. Hiatal hernias are usually asymptomatic but can cause heartburn, chest pain, abdominal pain, and difficulty swallowing. Treatment involves lifestyle modifications and medication for symptoms, while paraesophageal hernias may require surgical repair.

1. Hiatal Hernias

2. Classic Clinical Vignette
45 y/o guy presents to ED
with chest pain, difficulty
swallowing, and heartburn
after meals, especially when
reclining. His CXR is shown
on the right.

3. What is a Hiatal Hernia?
• Herniation of stomach through diaphragm into the chest cavity
• 2 key types of hiatal hernias: Sliding vs Paraesophageal
• Technically, there are 4 types according to Hill’s Classification – but Sliding Hiatal Hernia and
Paraesophageal Hiatal Hernia are the 2 that are MC tested

4. Type 1 vs Type 2 Hiatal Hernia
Type 1 Type 2
Stomach slides into mediastinum Stomach fundus rolls through
diaphragm
Occurs at GEJ GEJ remains intra-abdominal
80% of cases associated w/GERD Parallel to esophagus

5. Other Types of Hiatal Hernia
• Type 3: Combination of Type 1 and Type 2
• Type 4: Abdominal organ (eg colon or spleen) +/- stomach herniate
into chest cavity

6. Epidemiology
• Estimated 10% of adult population in US has a hiatal hernia!
• Occurs most commonly in women in their 5th and 6th decades
• Type 1 (~95%) > Type 2 (5%)

7. Risk Factors
• Age - biggest risk factor, related to loss of diaphragmatic tone
• Pregnancy
• Obesity
• Ascites
Due to ↑ intra-abdominal
pressure and superior
displacement of viscera

8. Presentation (S/Sx)
Symptoms:
• May be asymptomatic (identified
incidentally)
• Heartburn
• Chest pain
• Abdominal pain
• GERD (especially in sliding hiatal hernias)
• Dysphagia with solids
• Belching
Physical Exam:
• Usually ∅ significant findings
• May hear bowel sounds in chest

9. Workup
★ Usually an incidental finding
• Barium Swallow: VERY helpful in establishing diagnosis; Shows anatomy & size of hernia,
orientation of stomach, and location of GEJ
• CXR: Retrocardiac air bubble (air-fluid level in posterior mediastinum); however, CXR may
be normal
• CT scan/MRI: Stomach is partially or completely intrathoracic +/- herniation of other
intra-abdominal organs into chest
• Esophageal manometry: Double hump configuration on manometry; pH may be
abnormal as well
• Upper Endoscopy: Helps to rule out other esophageal/gastric pathologies; Retroflexion
maneuver can be used to detect paraesophageal hernias
• Ambulatory pH testing: Helps in planning appropriate intervention and to establish a
baseline of acid reflux for follow-up

10. Barium Swallow - Images
Source: 2017
UpToDate

11. DDx
• Diffuse Esophageal Spasm (DES):
Manometry → Large # of non-peristaltic
esophageal contractions
• Nutcracker Esophagus: Manometry →
esophageal contractions are peristaltic
but of large amplitude
• Achalasia: Manometry → LES is
hypertensive & fails to relax in swallows
• GERD: Incompetent LES
• Other important DDx to consider and
exclude are: Cardiac chest pain,
Pancreatic cancer, Esophageal cancer,
Gastric cancer
Esophageal motility disorders
W.G. Paterson, Raj K. Goyal and Fortunée Irene Habib
GI Motility online (2006)
doi:10.1038/gimo20

12. DDx continued
• Other important differential to consider and exclude are:
• Cardiac chest pain
• Pancreatic cancer
• Gastric cancer

13. Management
• Sliding Hiatal Hernia – Surgical repair of an isolated Type 1 Hiatal Hernia is
usually not needed. Mgmt consists of addressing associated GERD. 1st line
therapy consists of PPI (eg omeprazole) and lifestyle modifications (eg
weight loss, low fat, earlier meals, smaller portions). If symptoms persist
despite maximal medical tx, surgery may be considered.
• Paraesophageal Hiatal Hernia – If symptomatic → surgical repair is
indicated. Emergent surgical repair may be needed in pts with gastric
volvulus, perforation, gastric outlet obstruction, strangulation and/or
respiratory compromise secondary to the paraesophageal hernia. Mgmt of
asymptomatic paraesophageal hiatal hernias is somewhat more
controversial - however, most experts are opposed to PPx surgical repair.

14. Paraesophageal Hernia Repair (PEHR)
• Can be performed either transabdominally or transthoracically
• Transabdominal repair consists of complete mediastinal hernia sac dissection and
reduction, relocating GEJ intra-abdominally, stable crural closure, antireflux
procedure (eg Nissen fundoplication), and intra-abdominal gastric fixation
• Transabdominal repair can be done laparoscopically or open. Laparoscopic
transabdominal PEHR preferred in most pts, both in elective and emergent cases
• Note: Laparoscopic PEHR has higher (but clinically insignificant) radiographic recurrence rate
than the other two approaches (transabdominal open and transthoracic)
• Transthoracic approach typically reserved for pts who failed previous open
transabdominal repair
• Routine use of mesh during PEHR is not recommended (Grade 2C) – due to
potential for complications (eg erosion or stenosis of esophagus)

15. Post Op Care for Transabdominal PEHR
• Admission to hospital
• Antiemetics for first 24 hrs - post-op vomiting → disruption of repair
and possible early recurrence
• Barium swallow on POD 1 - to assess for esophageal leaks or early
recurrence & to evaluate gastric emptying/motility
• Discharge - usu on POD 2 if laparoscopic PEHR, POD 5 for open PEHR
• Low residue diet - recommended for 2-3 wks following discharge

16. References
• Kahrilas PJ. Hiatus Hernia. In: UpToDate, Post TW (Ed). UpToDate, Waltham, MA.
Accessed on March 10, 2017
• Klingensmith M. The Washington Manual Of Surgery. 1st edition. Lippincott
Williams & Wilkins. 2008.
• Hiatus Hernia. TeachMeSurgery.com. 2016. Available from
http://teachmesurgery.com/general/gastric/hiatus-hernia/. Accessed on March
10, 2017.
• Paterson WG, Goyal RK, Habib FI. Esophageal motility disorders. GI Motility
Online (2006). doi: 10.1038/gimo20.
• Rosen M, Blatnik J. Surgical management of paraesophageal hernia. In: UpToDate,
Post TW (Ed), UpToDate, Waltham, MA. Accessed on March 10, 2017.