Hiatal 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 gastroesophageal reflux disease and has been treated with proton-pump inhibitors. His heartburn is less severe with drugs, but he still is bothered by regurgitation. His physical examination is unremarkable. A barium esophagram and upper gastrointestinal endoscopy demonstrate a type I (sliding) hiatal hernia, with about one-third of the upper stomach in the chest. The patient has free reflux to the level of the cervical esophagus.

Other presentations

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

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

Patients with paraesophageal hernias (i.e., type II-IV hiatal hernias) often have pain or difficulty with swallowing (odynophagia or dysphagia), early satiety, and bloating. However, patients with type II-IV hiatal 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.