Hernia of the Stomach (Hiatal Hernia)

A hiatal hernia is the herniation of viscera - most commonly the stomach - into the mediastinum through the esophageal hiatus of the diaphragm. It is the most clinically important hernia of the stomach.

Classification (4 Types)

Type	Name	Description
I	Sliding hernia	The esophagogastric junction (EGJ) AND gastric cardia herniate above the diaphragm; stomach axis is unchanged. Accounts for ~90-95% of all hiatal hernias.
II	True paraesophageal hernia	Fundus of stomach herniates alongside the esophagus while the EGJ stays normally positioned below the diaphragm.
III	Mixed (combined) hernia	Both the EGJ is above the hiatus AND a portion of the stomach is folded alongside the esophagus. Most "paraesophageal" hernias in practice are this type.
IV	Complex hernia	Additional intra-abdominal organs (colon, omentum, spleen) also herniate through the hiatus.

Types II, III, and IV are collectively called paraesophageal hernias (PEH).

Types of hiatal hernia with barium studies and endoscopy

Fig. A: Paraesophageal (type II) hernia - barium study showing stomach above diaphragm with organoaxial volvulus (B). C: Endoscopic view of a large PEH. D: Cameron lesion. E: Laparoscopic view. - Sleisenger and Fordtran's GI and Liver Disease

Anatomy & Pathophysiology

The phrenoesophageal ligament (membrane) normally anchors the EGJ to the diaphragm at the hiatus. Hiatal hernias result from:

Age-related deterioration of this membrane
Dilatation of the diaphragmatic hiatus
Chronic elevated intra-abdominal pressure (obesity, pregnancy, chronic straining)
Esophageal traction pulling the stomach cephalad during swallowing

Type I hernias are essentially "wear and tear" hernias - they enlarge with increased intra-abdominal pressure, swallowing, and respiration.

With types II and III, the stomach progressively inverts as it herniates - large PEH can lead to an "upside-down stomach" and gastric volvulus.

Harrison's Principles of Internal Medicine 22E, p. 2549
Sleisenger and Fordtran's GI and Liver Disease

Epidemiology

Prevalence varies widely (14-84%) depending on population and diagnostic method
More frequent in patients with GERD
Incidence increases with age
Symptomatic PEH most commonly presents in middle-aged to older adults

Clinical Features

Type I (Sliding) Hernia

Often asymptomatic when small
Main significance: predisposition to GERD (heartburn, regurgitation)
Large hernias may cause dysphagia, chest or upper abdominal discomfort
Cameron lesions (linear erosions at lesser curve at the diaphragmatic hiatus level) occur in ~5% of hiatal hernia patients, up to ~30% in large PEH - can cause iron deficiency anemia

Types II, III, IV (Paraesophageal Hernias)

Rarely fully asymptomatic; symptoms include:

Early satiety and postprandial fullness
Dysphagia and chest pain
Shortness of breath (post-prandial) from intrathoracic stomach
Iron deficiency anemia (30-40%) from chronic GI blood loss via Cameron lesions
Weight loss and vomiting
Risk of gastric volvulus - a potentially life-threatening complication presenting with acute pain and retching, progressing to strangulation and perforation

Investigations

Test	Findings
Chest X-ray	Soft tissue density or air-fluid level in retrocardiac area
Barium swallow (UGI)	Best initial test - shows stomach above diaphragm, type of hernia, presence of volvulus
CT scan	Excellent for type IV - delineates anatomy, identifies organs herniated (colon, spleen, pancreas)
Upper endoscopy	Confirms diagnosis; detects esophagitis, gastritis, Cameron lesions, malignancy
Esophageal manometry	Assesses motility disorders; guides fundoplication choice
24-hr pH/impedance	Confirms GERD, quantifies acid exposure

Treatment

Medical (Type I / Asymptomatic)

Simple sliding hernias do not require treatment unless symptomatic from reflux
Proton pump inhibitors (PPIs) for GERD management
Lifestyle modifications (weight loss, head-of-bed elevation, dietary changes)

Surgical Indications

Surgery is offered when:

Symptomatic PEH (types II, III, IV) - postprandial pain, dysphagia, weight loss, anemia
Gastric volvulus or strangulation (emergency)
Cameron lesions with significant blood loss
Failed medical management of reflux

Elective repair is preferred; emergency risk is lower than historically believed. Most experts advocate repair for symptomatic PEH; some advocate repair for all PEH due to complication risk.

Principles of Surgical Repair (4 Key Steps)

Reduction of the hernia from the mediastinum/chest with excision of the hernia sac
Reconstruction of the diaphragmatic hiatus - posterior crural closure with or without prosthetic mesh
Fundoplication (partial or complete wrap) - prevents post-op reflux, provides bulk at hiatus
Gastropexy or gastrostomy tube - additional fixation of the stomach intra-abdominally, reduces recurrence

Surgical Approaches

Laparoscopic (preferred) - minimally invasive, lower morbidity
Open upper midline laparotomy - for reoperative or complex cases where laparoscopic approach is unsafe
Left thoracotomy - historical standard; now reserved for select complex cases

A Nissen (360°) or Toupet (270° posterior) fundoplication is typically added. If esophageal shortening is present, a Collis gastroplasty may be needed to create adequate intra-abdominal esophageal length.

Current Surgical Therapy 14e
Sleisenger and Fordtran's GI and Liver Disease

Complications of Untreated PEH

Gastric volvulus (organoaxial or mesenteroaxial)
Gastric incarceration and strangulation
Perforation
Obstructive symptoms (dysphagia, obstruction)
Chronic hemorrhage (Cameron lesions)

Recent Evidence

Recent systematic reviews (2024-2025) have addressed surgical nuances:

Ligamentum teres augmentation for hiatal repair after bariatric surgery shows favorable outcomes (PMID: 38946644)
Transoral incisionless fundoplication + hiatal repair shows efficacy for refractory GERD with hiatal hernia (PMID: 39271515)
Mesh vs. no mesh for recurrent hiatal hernia repair - meta-analysis 2025 comparing reinforcement strategies (PMID: 40459749)

Key clinical pearl: A type I hernia is benign in most cases - treat the GERD, not the hernia. A large type III or IV paraesophageal hernia with symptoms is a surgical lesion; delay risks catastrophic volvulus and strangulation.

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