Hiatal Hernia: Types, Aetiology, Pathophysiology , Clinical manifestations , Diagnosis & Management

By March 10, 2017 No Comments
Hiatal Hernia: Types, Aetiology, Pathophysiology , Clinical manifestations , Diagnosis & Management

A hernia is a protrusion of a portion of an organ or tissue through an abnormal opening.

Herniation is an abnormal protrusion of an organ or other body structure through a defect or natural opening in a covering membrane, muscle or bone.

A Hiatal Hernia is a conduction in which the cardiac sphincter becomes enlarged allowing a part of the stomach to pass into the thoracic cavity. Hence, a hiatal hernia is the herniation of a portion of the stomach into the esophagus through an opening or hiatus in the diaphragm.

It is also referred to as a diaphragmatic hernia and esophageal hernia.

Types of a hiatal hernia

  • Type I hiatal a hernia (Sliding)
  • Type II Paraesophageal hiatal/ rolling hiatal hernia
  • III hiatal hernia type III hernias are the combined hernias in which the gastroesophageal junction is herniated above the diaphragm and the stomach is herniated alongside the esophagus.
  • And Type IV hiatal hernia  other organs in addition to the stomach also herniate into the chest

Type I hiatal (Sliding hiatal hernia)

Sliding Hiatal hernias are those in which the junction of the esophagus and stomach called as gastroesophageal junction and part of the stomach protrude into the chest.

Type II (Paraesophageal hiatal/ rolling) a hiatal hernia

In this type of a hernia, the stomach herniates through the diaphragmatic esophageal hiatus alongside the esophagus. It is also called “pure” a Paraesophageal hernia, the gastro esophageal junction remains below the hiatus. The stomach rotates in front of the esophagus and herniates into the chest.

Type III a hiatal hernia

They are the combined hernias in which the gastroesophageal junction is herniated above the diaphragm. The esophagus herniates the stomach alongside.

Type IV hiatal hernia

Stomach adds other organs also herniate into the chest


The actual causes of a hiatal hernia are unknown. Many factors contribute to the development of a hiatal hernia

Structural changes, weakening of the muscles in diaphragm around the esophagogastric opening are usually contributing factors. This causes to loosen the esophageal support and allow the lower portion of the stomach to rise into the thorax. Variety of conditions such as aging, trauma, congenital, surgery etc. causes muscles weakness.

Factors that increase the abdominal pressure including obesity, pregnancy, ascites, tumor, intense physical exertion, tight corsets and heavy lifting.

Poor nutrition and forced recumbent position as when a prolonged illness confines the patient to bed.


A hiatal hernia involves herniation of part of the stomach through a weakness in the diaphragm. The resulting regurgitation and motor dysfunction cause the major manifestation of a hiatal hernia. With sliding hernia the problems are rarely anatomical. The problems relate directly to the functional consequences of chronic reflux.

Reflux occurs from the ongoing exposure of lower esophageal sphincter to the low-pressure environment of the thorax where sphincter function is significantly impaired. Reflux Is rarely a concern with rolling hernia because lower esophageal sphincter remains anchored below the diaphragm. However, anatomical risks of volvulus, strangulation, and obstruction are high. Venous obstruction in a herniated portion of the stomach causes the mucosa to become engaged and to ooze. Slow bleeding leads to the development of iron deficiency anemia, but significantly bleeding is rare.

Clinical manifestations

Clinical manifestations vary according to the type and severity of a hernia.

  1. In sliding hernia
  • Heartburn  
  • Regurgitation
  • Dysphagia
  1. In a Paraesophageal hernia
  • Feels the sense of fullness or chest pain after eating
  • Sitting or standing usually relieves burning pain.
  • Nocturnal attacks are common especially if person has eaten before going to sleep
  • Anemia is the most common laboratory finding in patients with type II a hiatal hernia.
  • A chronic cough is caused by aspiration of acid particles in the airway.


  • Barium swallow: Before taking  X-ray Doctor provides a liquid with barium to the patient. This X-ray provides a clear view of the upper digestive tract and helps to see the location of a hernia in the stomach.
  • X-ray studies
  • Esophageal manometry
  • Videoesophagram: This study shows the anatomy of the gastroesophageal junction, the position of the stomach and the presence of the other intra-abdominal organs in the chest. It helps to reveal the esophageal emptying.
  • Esophagoscopy/ endoscopy: A thin tube is inserted through a mouth and pass down to the esophagus and stomach which helps to visualize any strangulation or obstruction in it.
  • Esophageal biopsy, cytologic examination, and analysis of gastric secretion.

Management of Hiatal Hernia

Medical management

  1. Decrease reflux with medication including antacids H2 receptor antagonist, cholinergic, GI stimulants proton pump inhibitors may be used for treatment.
  2. Decrease reflux with lifestyle and diet changes
  3. Restrict the diet to small, frequent feeding (4-6 per day)
  4. Eat slowly and chew thoroughly to add saliva to food
  5. Avoid extremely hot or cold foods, spices, fats, alcohol, coffee, citrus juices to decrease acid
  6. Encourage protein diet
  7. Elevate the head of bed to 6-8 inch to prevent nocturnal reflux
  8. Avoid constricting cloth and heavy lifting
  9. Obese client are encouraged to lose weight
  10. Encourage to avoid drinking fluids with meals to limit the volume in the stomach

Surgical Management

The treatment of large sliding hiatal hernia and Paraesophageal hernias require surgery to correct the anatomy, reduce a hernia and repair the opening in the diaphragm. About 15% of patients do surgery.

Clients who don’t respond to medical management undergo one of three surgical procedure.

  • The Nissen fundoplication:

It involves suturing the fundus around the esophagus. The surgeon creates a valve like a substitute sphincter with inherent contractility.

  • The Hill operation:

This procedure narrows esophageal opening and anchors the stomach and distal esophagus to the median arcuate ligament

Prevention of Hiatal Hernia

The following ways can prevent the symptoms of hiatal hernia:

    • Wearing loose clothing which prevents the press on the stomach
    • Avoid bending over or lying down when after eating food which increases the abdominal pressure thus increases the heartburn
    • Do not bend or lie down for about two or three hours soon after eating
    • Raise your head of the bed to about six or eight inches to prevent from refluxes.

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