- Peter J Kahrilas, MD
Peter J Kahrilas, MD
- Professor of Medicine
- Feinberg School of Medicine, Northwestern University
Hiatus hernia is a frequent finding by both radiologists (image 1) and gastroenterologists. However, estimates of the prevalence of hiatus hernia vary widely due to inconsistency in the definition. There is also confusion regarding the normal function of the gastroesophageal junction and the clinical implications of a hiatus hernia.
This topic will review the pathophysiology, classification, clinical manifestations, diagnosis, and management of a hiatus hernia. The surgical management of paraesophageal hernia and the management of gastroesophageal reflux disease are discussed separately. (See "Surgical management of paraesophageal hernia" and "Medical management of gastroesophageal reflux disease in adults" and "Approach to refractory gastroesophageal reflux disease in adults".)
ANATOMY AND PHYSIOLOGY OF THE GASTROESOPHAGEAL JUNCTION
The distal end of the esophagus is anchored to the diaphragm by the phrenoesophageal membrane, formed by the fused endothoracic and endoabdominal fascia. This elastic membrane inserts circumferentially into the esophageal musculature, very close to the squamocolumnar junction, which resides within the diaphragmatic hiatus.
This configuration is altered during swallow-initiated peristalsis, a sequenced contraction of both the longitudinal and circular muscle responsible for bolus propulsion through the esophagus . With contraction of the esophageal longitudinal muscle, the esophagus shortens and the phrenoesophageal membrane is stretched; its elastic recoil is then responsible for pulling the squamocolumnar junction back to its normal position following each swallow. This is, in effect, "physiologic herniation," since the gastric cardia tents through the diaphragmatic hiatus with each swallow (figure 1) .
The globular structure seen radiographically that forms above the diaphragm and beneath the tubular esophagus during deglutition is termed the phrenic ampulla; it is bounded from above by the distal esophagus and from below by the crural diaphragm (figure 2) . Physiologically, the phrenic ampulla is the relaxed, effaced, and elongated lower esophageal sphincter (LES) . Emptying of the ampulla occurs between inspirations in conjunction with relengthening of the esophagus and contraction of the LES [4,5].
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- ANATOMY AND PHYSIOLOGY OF THE GASTROESOPHAGEAL JUNCTION
- Type I: Sliding hernia
- Type II, III, IV: Paraesophageal hernias
- Type I: Sliding hernia
- - Mechanism of gastroesophageal reflux in type I hiatus hernia
- Type II, III, and IV: Paraesophageal hernias
- CLINICAL FEATURES
- Clinical manifestations
- Radiographic findings
- Barium swallow
- Upper endoscopy
- High resolution manometry
- DIFFERENTIAL DIAGNOSIS
- Sliding hiatus hernia
- Paraesophageal hernia
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS