Hiatus hernia

Case history

A 51-year-old man with moderate obesity (body mass index of 34 kg/m²) is seen in consultation for heartburn and regurgitation. He has a diagnosis of gastro-oesophageal reflux disease and has been treated with proton-pump inhibitors. His heartburn is less severe with drugs, but he is still bothered by regurgitation. His physical examination is unremarkable. A barium oesophagram and upper gastrointestinal endoscopy demonstrate a type I (sliding) hiatus hernia, with about one third of the upper stomach in the chest. The patient has free reflux to the level of the cervical oesophagus.

Other presentations

Most hiatus hernias are minimally symptomatic or asymptomatic, especially small type I hiatus hernias.

In patients with symptomatic hiatus hernia, heartburn and other symptoms of gastro-oesophageal reflux disease are the most common complaints, due to the compromised state of the lower oesophageal sphincter. Physical findings are minimal, except in severe cases involving bleeding, necrosis, or both.

Patients with para-oesophageal hernias (i.e., type II-IV hiatus hernias) often have pain or difficulty with swallowing (odynophagia or dysphagia), early satiety, and bloating. However, patients with type II-IV hiatus hernias may be completely asymptomatic, and on rare occasions, may present unpredictably with gastric volvulus, obstruction, or necrosis, or some combination of these. At times, patients may have chest pain mimicking angina or myocardial infarction.