Etiology
A clear etiology for hiatal hernia is not known; etiology is probably multifactorial.[7][8][9]
During normal swallowing, the esophagus shortens several centimeters due to contraction of its longitudinal muscular layer. This action, in combination with elevations in intra-abdominal pressure such as from coughing, sneezing, straining, and strenuous exercise, produces physiologic movement of the distal esophagus and possibly the gastroesophageal junction through the esophageal hiatus and into the posterior mediastinum. This movement is countered by the resistance of the phrenoesophageal ligaments, which run between the diaphragm and the gastroesophageal junction. These ligaments are somewhat elastic in terms of their stretch and recoil.
Eventually the physiologic movement and stretching may enlarge the hiatus, leading to permanent residence of a portion of the stomach above the diaphragm.
Pathophysiology
In sliding hiatal hernia (type I), the displacement of the gastroesophageal junction above the diaphragm decreases the lower esophageal sphincter (LES) pressure.[7][10] Because the LES is the primary determinant of the antireflux valve, a decrease in LES pressure predisposes the patient to gastroesophageal reflux. Thus, the most common symptom of a symptomatic sliding hiatal hernia is reflux-associated heartburn, or pyrosis. It follows that the mainstay of treatment for a symptomatic sliding hiatal hernia is very similar to that for gastroesophageal reflux disease.
The situation for the relatively uncommon paraesophageal hernia (types II-IV) differs because the rotation and twisting of the stomach as it migrates into the chest can produce intermittent strangulation with obstruction and ischemia. This can result in pain, vomiting, ulcers, and necrosis. Pain from a paraesophageal hernia can easily be mistaken for angina pectoris. Ischemic ulcers can produce upper gastrointestinal hemorrhage with hematemesis. Ischemic necrosis of the stomach is one of the most feared complications of paraesophageal hernia. Such an event typically progresses rapidly to mediastinitis and death if left untreated.
[Figure caption and citation for the preceding image starts]: Types of hiatal herniaAdapted from “Paraesophageal Hernia Repair". Abdominal Key, 2019; used with permission [Citation ends].
Classification
Types of hiatal hernia[1]
Type I
Sliding hiatal hernia
Protrusion of the gastroesophageal junction followed by the body of the stomach through the esophageal hiatus and above the diaphragm
Most common type.
Type II
Pure paraesophageal hernia or rolling hiatal hernia
Herniation of the fundus or body of the stomach or both into the chest alongside the esophagus, with maintenance of the gastroesophageal junction in a normal anatomic position below the diaphragm.
Type III
Mixed or combined paraesophageal hernia
Combination of types I and II. The fundus or body of the stomach or both have herniated into the chest; the gastroesophageal junction is also herniated into the chest, but rests below the herniated stomach.
Type IV
Also known as giant hiatal hernia
Occurrence of any type of hiatal hernia along with herniation of one or more other organs, such as colon, small bowel, omentum, and spleen.
[Figure caption and citation for the preceding image starts]: Types of hiatal herniaAdapted from “Paraesophageal Hernia Repair". Abdominal Key, 2019; used with permission [Citation ends].
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