Hiatal Hernia

  • Sabine Roman
  • Peter J. KahrilasEmail author


Hiatal hernia is a condition in which elements of the abdominal cavity (most commonly the stomach) herniate through the esophageal hiatus into the mediastinum. Four types of hernias are described. Type I or sliding hernia is the most common. It consists of an anatomic disruption of the esophagogastric junction associated with a widening of the diaphragmatic hiatus and axial displacement separation of the lower esophageal sphincter and crural diaphragm. Type II, III and IV are ‘paraesophageal’ hernias resulting from a localized defect in the phrenoesophageal membrane. Age and obesity are factors associated with sliding hernia occurrence. A sliding hernia may be an intermittent phenomenon, especially when small, and may be an equivocal finding. Barium contrast radiography and endoscopy provide an anatomic description of the condition while high resolution esophageal manometry depicts a more physiological assessment. Thus, two high pressure zones are identified in sliding hiatal hernia: the lower esophageal sphincter and the crural diaphragm. Clinical presentation ranges from the absence of symptoms, to reflux, dysphagia, or chronic anemia.


Hiatal hernia Esophagogastric junction Mobility of the esophagogastric junction Phrenoesophageal membrane Obesity High-resolution manometry 



Body mass index


Crural diaphragm


Esophagogastric junction


High-resolution manometry


Lower esophageal sphincter


Squamocolumnar junction



This work was supported by R01DK56033 (PJK) from the Public Health Service


  1. 1.
    Marchand P. The anatomy of esophageal hiatus of the diaphragm and the pathogenesis of hiatus herniation. J Thorac Surg. 1959;37:81–92.PubMedGoogle Scholar
  2. 2.
    Jaffee BM. Surgery of the esophagus. In: Orlando RC, editor. Atlas of esophageal diseases. 2nd ed. Philadelphia: CurrentMedicine; 2002. p. 223–42.Google Scholar
  3. 3.
    Barrett NR. Discussion on hiatus hernia. Proc R Soc Med. 1932;122:736–96.Google Scholar
  4. 4.
    Schatzki R. Die hernien des hiatus oesophagus. Deutsches Arch f klin Med. 1932;173:85–103.Google Scholar
  5. 5.
    Kahrilas PJ, Lin S, Chen J, Manka M. The effect of hiatus hernia on gastro-oesophageal junction pressure. Gut. 1999;44:476–82.PubMedCrossRefGoogle Scholar
  6. 6.
    Wolf BS. Sliding hiatal hernia: the need for redefinition. Am J Roentgenol Radium Ther Nucl Med. 1973;117:231–47.PubMedGoogle Scholar
  7. 7.
    Friedland GW. Progress in radiology: historical review of the changing concepts of lower esophageal anatomy: 430 B.C.–1977. AJR Am J Roentgenol. 1978;131:373–8.PubMedGoogle Scholar
  8. 8.
    Pouderoux P, Lin S, Kahrilas PJ. Timing, propagation, coordination, and effect of esophageal shortening during peristalsis. Gastroenterology. 1997;112:1147–54.PubMedCrossRefGoogle Scholar
  9. 9.
    Shi G, Pandolfino JE, Joehl RJ, Brasseur JG, Kahrilas PJ. Distinct patterns of oesophageal shortening during primary peristalsis, secondary peristalsis and transient lower oesophageal sphincter relaxation. Neurogastroenterol Motil. 2002;14:505–12.PubMedCrossRefGoogle Scholar
  10. 10.
    Kahrilas PJ, Wu S, Lin S, Pouderoux P. Attenuation of esophageal shortening during peristalsis with hiatus hernia. Gastroenterology. 1995;109:1818–25.PubMedCrossRefGoogle Scholar
  11. 11.
    Pandolfino JE, Zhang QG, Ghosh SK, Han A, Boniquit C, Kahrilas PJ. Transient lower esophageal sphincter relaxations and reflux: mechanistic analysis using concurrent fluoroscopy and high-resolution manometry. Gastroenterology. 2006;131:1725–33.PubMedCrossRefGoogle Scholar
  12. 12.
    Pandolfino JE, Schreiner MA, Lee TJ, Zhang Q, Boniquit C, Kahrilas PJ. Comparison of the bravo wireless and digitrapper catheter-based pH monitoring systems for measuring esophageal acid exposure. Am J Gastroenterol. 2005;100:1466–76.PubMedCrossRefGoogle Scholar
  13. 13.
    Pandolfino JE, Shi G, Trueworthy B, Kahrilas PJ. Esophagogastric junction opening during relaxation distinguishes nonhernia reflux patients, hernia patients, and normal subjects. Gastroenterology. 2003;125:1018–24.PubMedCrossRefGoogle Scholar
  14. 14.
    Skinner DB. Hernia (hiatal, traumatic, and congenital). In: Berk JE, editor. Gastroenterology. 4th ed. Philadelphia: Saunders; 1985. p. 705–16. Chapter 53.Google Scholar
  15. 15.
    Menon S, Trudgill N. Risk factors in the aetiology of hiatus hernia: a meta-analysis. Eur J Gastroenterol Hepatol. 2011;23:133–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Schuchert MJ, Adusumilli PS, Cook CC, Colovos C, Kilic A, Nason KS, Landreneau JP, Zikos T, Jack R, Luketich JD, Landreneau RJ. The impact of scoliosis among patients with giant paraesophageal hernia. J Gastrointest Surg. 2011;15:23–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Kusano M, Hashizume K, Ehara Y, Shimoyama Y, Kawamura O, Mori M. Size of hiatus hernia correlates with severity of kyphosis, not with obesity, in elderly Japanese women. J Clin Gastroenterol. 2008;42:345–50.PubMedCrossRefGoogle Scholar
  18. 18.
    Polomsky M, Siddall KA, Salvador R, Dubecz A, Donahue LA, Raymond D, Jones C, Watson TJ, Peters JH. Association of kyphosis and spinal skeletal abnormalities with intrathoracic stomach: a link toward understanding its pathogenesis. J Am Coll Surg. 2009;208:562–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Yoshimura M, Nagahara A, Ohtaka K, Shimada Y, Asaoka D, Kurosawa A, Osada T, Kawabe M, Hojo M, Yoshizawa T, Watanabe S. Presence of vertebral fractures is highly associated with hiatal hernia and reflux esophagitis in Japanese elderly people. Intern Med. 2008;47:1451–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Sakaguchi M, Oka H, Hashimoto T, Asakuma Y, Takao M, Gon G, Yamamoto M, Tsuji Y, Yamamoto N, Shimada M, Lee K, Ashida K. Obesity as a risk factor for GERD in Japan. J Gastroenterol. 2008;43:57–62.PubMedCrossRefGoogle Scholar
  21. 21.
    Wilson LJ, Ma W, Hirschowitz BI. Association of obesity with hiatal hernia and esophagitis. Am J Gastroenterol. 1999;94:2840–4.PubMedCrossRefGoogle Scholar
  22. 22.
    Stene-Larsen G, Weberg R, Froyshov Larsen I, Bjortuft O, Hoel B, Berstad A. Relationship of overweight to hiatus hernia and reflux oesophagitis. Scand J Gastroenterol. 1988;23:427–32.PubMedCrossRefGoogle Scholar
  23. 23.
    Wu AH, Tseng CC, Bernstein L. Hiatal hernia, reflux symptoms, body size, and risk of esophageal and gastric adenocarcinoma. Cancer. 2003;98:940–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Pandolfino JE, El-Serag HB, Zhang Q, Shah N, Ghosh SK, Kahrilas PJ. Obesity: a challenge to esophagogastric junction integrity. Gastroenterology. 2006;130:639–49.PubMedCrossRefGoogle Scholar
  25. 25.
    de Vries DR, van Herwaarden MA, Smout AJ, Samsom M. Gastroesophageal pressure gradients in gastroesophageal reflux disease: relations with hiatal hernia, body mass index, and esophageal acid exposure. Am J Gastroenterol. 2008;103:1349–54.PubMedCrossRefGoogle Scholar
  26. 26.
    Smith AB, Dickerman RD, McGuire CS, East JW, McConathy WJ, Pearson HF. Pressure-overload-induced sliding hiatal hernia in power athletes. J Clin Gastroenterol. 1999;28:352–4.PubMedCrossRefGoogle Scholar
  27. 27.
    Eren S, Ciris F. Diaphragmatic hernia: diagnostic approaches with review of the literature. Eur J Radiol. 2005;54:448–59.PubMedCrossRefGoogle Scholar
  28. 28.
    Karpelowsky JS, Wieselthaler N, Rode H. Primary paraesophageal hernia in children. J Pediatr Surg. 2006;41:1588–93.PubMedCrossRefGoogle Scholar
  29. 29.
    Ott DJ, Gelfand DW, Chen YM, Wu WC, Munitz HA. Predictive relationship of hiatal hernia to reflux esophagitis. Gastrointest Radiol. 1985;10:317–20.PubMedCrossRefGoogle Scholar
  30. 30.
    Stilson WL, Sanders I, Gardiner GA, Gorman HC, Lodge DF. Hiatal hernia and gastroesophageal reflux. A clinicoradiological analysis of more than 1,000 cases. Radiology. 1969;93:1323–7.PubMedGoogle Scholar
  31. 31.
    Bytzer P. Information bias in endoscopic assessment. Am J Gastroenterol. 2007;102:1585–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Hill LD, Kraemer SJ, Aye RW. Laparoscopic hill repair. Contemp Surg. 1994;44:1.Google Scholar
  33. 33.
    Hill LD, Kozarek RA, Kraemer SJ, Aye RW, Mercer CD, Low DE, Pope 2nd CE. The gastroesophageal flap valve: in vitro and in vivo observations. Gastrointest Endosc. 1996;44:541–7.PubMedCrossRefGoogle Scholar
  34. 34.
    Seltman AK, Kahrilas PJ, Chang EY, Mori M, Hunter JG, Jobe BA. Endoscopic measurement of cardia circumference as an indicator of GERD. Gastrointest Endosc. 2006;63:22–31.PubMedCrossRefGoogle Scholar
  35. 35.
    Pandolfino JE, Kim H, Ghosh SK, Clarke JO, Zhang Q, Kahrilas PJ. High-resolution manometry of the EGJ: an analysis of crural diaphragm function in GERD. Am J Gastroenterol. 2007;102:1056–63.PubMedCrossRefGoogle Scholar
  36. 36.
    Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Intermittent spatial separation of diaphragm and lower esophageal sphincter favors acidic and weakly acidic reflux. Gastroenterology. 2006;130:334–40.PubMedCrossRefGoogle Scholar
  37. 37.
    Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22:601–16.PubMedCrossRefGoogle Scholar
  38. 38.
    Thukkani N, Sonnenberg A. The influence of environmental risk factors in hospitalization for gastro-oesophageal reflux disease-related diagnoses in the United States. Aliment Pharmacol Ther. 2010;31:852–61.PubMedGoogle Scholar
  39. 39.
    Annibale B, Capurso G, Chistolini A, D’Ambra G, DiGiulio E, Monarca B, DelleFave G. Gastrointestinal causes of refractory iron deficiency anemia in patients without gastrointestinal symptoms. Am J Med. 2001;111:439–45.PubMedCrossRefGoogle Scholar
  40. 40.
    Maganty K, Smith RL. Cameron lesions: unusual cause of gastrointestinal bleeding and anemia. Digestion. 2008;77:214–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Jones MP, Sloan SS, Rabine JC, Ebert CC, Huang CF, Kahrilas PJ. Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease. Am J Gastroenterol. 2001;96:1711–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Jones MP, Sloan SS, Jovanovic B, Kahrilas PJ. Impaired egress rather than increased access: an important independent predictor of erosive oeso­phagitis. Neurogastroenterol Motil. 2002;14:625–31.PubMedCrossRefGoogle Scholar
  43. 43.
    Pandolfino JE, Shi G, Curry J, Joehl RJ, Brasseur JG, Kahrilas PJ. Esophagogastric junction distensibility: a factor contributing to sphincter incompetence. Am J Physiol Gastrointest Liver Physiol. 2002;282:G1052–8.PubMedGoogle Scholar
  44. 44.
    Mittal RK, Lange RC, McCallum RW. Identification and mechanism of delayed esophageal acid clearance in subjects with hiatus hernia. Gastroenterology. 1987;92:130–5.PubMedGoogle Scholar
  45. 45.
    Sloan S, Kahrilas PJ. Impairment of esophageal emptying with hiatal hernia. Gastroenterology. 1991;100:596–605.PubMedGoogle Scholar
  46. 46.
    Beaumont H, Bennink RJ, de Jong J, Boeckxstaens GE. The position of the acid pocket as a major risk factor for acidic reflux in healthy subjects and patients with GORD. Gut. 2010;59:441–51.PubMedCrossRefGoogle Scholar
  47. 47.
    Lin S, Brasseur JG, Pouderoux P, Kahrilas PJ. The phrenic ampulla: distal esophagus or potential hiatal hernia? Am J Physiol. 1995;268:G320–7.PubMedGoogle Scholar
  48. 48.
    Scherer JR, Kwiatek MA, Soper NJ, Pandolfino JE, Kahrilas PJ. Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia. J Gastrointest Surg. 2009;13:2219–25.PubMedCrossRefGoogle Scholar
  49. 49.
    Pandolfino JE, Kwiatek MA, Ho K, Scherer JR, Kahrilas PJ. Unique features of esophagogastric junction pressure topography in hiatus hernia patients with dysphagia. Surgery. 2010;147:57–64.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Digestive PhysiologyHospices Civils de Lyon and Claude Bernard University, Hopital E HerriotLyonFrance
  2. 2.Department of GastroenterologyNorthwestern University HospitalChicagoUSA

Personalised recommendations