- 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].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Pouderoux P, Lin S, Kahrilas PJ. Timing, propagation, coordination, and effect of esophageal shortening during peristalsis. Gastroenterology 1997; 112:1147.
- Kahrilas PJ, Wu S, Lin S, Pouderoux P. Attenuation of esophageal shortening during peristalsis with hiatus hernia. Gastroenterology 1995; 109:1818.
- Kahrilas PJ. Hiatus hernia causes reflux: Fact or fiction? Gullet 1993; 3(Suppl):21.
- Kwiatek MA, Pandolfino JE, Kahrilas PJ. 3D-high resolution manometry of the esophagogastric junction. Neurogastroenterol Motil 2011; 23:e461.
- Lin S, Brasseur JG, Pouderoux P, Kahrilas PJ. The phrenic ampulla: distal esophagus or potential hiatal hernia? Am J Physiol 1995; 268:G320.
- Paterson WG, Kolyn DM. Esophageal shortening induced by short-term intraluminal acid perfusion in opossum: a cause for hiatus hernia? Gastroenterology 1994; 107:1736.
- Liebermann-Meffert D, Allgöwer M, Schmid P, Blum AL. Muscular equivalent of the lower esophageal sphincter. Gastroenterology 1979; 76:31.
- Weston AP. Hiatal hernia with cameron ulcers and erosions. Gastrointest Endosc Clin N Am 1996; 6:671.
- Mittal RK, Rochester DF, McCallum RW. Sphincteric action of the diaphragm during a relaxed lower esophageal sphincter in humans. Am J Physiol 1989; 256:G139.
- Kaiser LR, Singal S. Diaphragm. In: Surgical Foundations: Essentials of Thoracic Surgery, Elsevier Mosby, Philadelphia, PA 2004. p.294.
- Miller JI Jr. Chapter 89. Bacterial infections of the lungs and bronchial compressive disorders. In: General Thoracic Surgery, 7th ed, Shields TW, LoCicero J, Reed CE, Feins RH. (Eds), Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia 2009. Vol 1, p.294.
- Peridikis G, Hinder RA. Paraesophageal hiatal hernia. In: Hernia, Nyhus LM, Condon RE (Eds), JB Lippincott, Philadelphia 1995. p.544.
- Hill LD, Kozarek RA, Kraemer SJ, et al. The gastroesophageal flap valve: in vitro and in vivo observations. Gastrointest Endosc 1996; 44:541.
- Hill LD, Kraemer SJ, Aye RW, et al. Laparoscopic Hill repair. Contemp Surg 1994; 44:13.
- Wright RA, Hurwitz AL. Relationship of hiatal hernia to endoscopically proved reflux esophagitis. Dig Dis Sci 1979; 24:311.
- Boyle JT, Altschuler SM, Nixon TE, et al. Role of the diaphragm in the genesis of lower esophageal sphincter pressure in the cat. Gastroenterology 1985; 88:723.
- Boyle JT, Altschuler SM, Nixon TE, et al. Responses of feline gastroesophageal junction to changes in abdominal pressure. Am J Physiol 1987; 253:G315.
- Mittal RK, Rochester DF, McCallum RW. Electrical and mechanical activity in the human lower esophageal sphincter during diaphragmatic contraction. J Clin Invest 1988; 81:1182.
- Mittal RK, Fisher M, McCallum RW, et al. Human lower esophageal sphincter pressure response to increased intra-abdominal pressure. Am J Physiol 1990; 258:G624.
- Sloan S, Rademaker AW, Kahrilas PJ. Determinants of gastroesophageal junction incompetence: hiatal hernia, lower esophageal sphincter, or both? Ann Intern Med 1992; 117:977.
- MICHELSON E, SIEGEL CI. THE ROLE OF THE PHRENICO-ESOPHAGEAL LIGAMENT IN THE LOWER ESOPHAGEAL SPHINCTER. Surg Gynecol Obstet 1964; 118:1291.
- Kahrilas PJ, Lin S, Chen J, Manka M. The effect of hiatus hernia on gastro-oesophageal junction pressure. Gut 1999; 44:476.
- 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.
- Kahrilas PJ, Shi G, Manka M, Joehl RJ. Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia. Gastroenterology 2000; 118:688.
- van Herwaarden MA, Samsom M, Smout AJ. Excess gastroesophageal reflux in patients with hiatus hernia is caused by mechanisms other than transient LES relaxations. Gastroenterology 2000; 119:1439.
- Johnson LF. 24-hour pH monitoring in the study of gastroesophageal reflux. J Clin Gastroenterol 1980; 2:387.
- Sloan S, Kahrilas PJ. Impairment of esophageal emptying with hiatal hernia. Gastroenterology 1991; 100:596.
- Mittal RK, Lange RC, McCallum RW. Identification and mechanism of delayed esophageal acid clearance in subjects with hiatus hernia. Gastroenterology 1987; 92:130.
- Ott DJ, Gelfand DW, Chen YM, et al. Predictive relationship of hiatal hernia to reflux esophagitis. Gastrointest Radiol 1985; 10:317.
- 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.
- Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol 2008; 22:601.
- Davis SS Jr. Current controversies in paraesophageal hernia repair. Surg Clin North Am 2008; 88:959.
- Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation? Ann Surg 2002; 236:492.
- Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic stomach. Presentation and results of operation. J Thorac Cardiovasc Surg 1993; 105:253.
- Hallissey MT, Ratliff DA, Temple JG. Paraoesophageal hiatus hernia: surgery for all ages. Ann R Coll Surg Engl 1992; 74:23.
- Pitcher DE, Curet MJ, Martin DT, et al. Successful laparoscopic repair of paraesophageal hernia. Arch Surg 1995; 130:590.
- Kohn GP, Price RR, DeMeester SR, et al. Guidelines for the management of hiatal hernia. Surg Endosc 2013; 27:4409.
- Hill LD. Incarcerated paraesophageal hernia. A surgical emergency. Am J Surg 1973; 126:286.
- Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J Thorac Cardiovasc Surg 1967; 53:33.
- 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