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Hernia de hiato
Autor: Peter J. Kahrilas, MD
Redactor de sección: Nicholas J. Talley, MD, PhD
Redactor adjunto: Shilpa Grover, MD, MPH, AGAF

Todos los temas se actualizan a medida que se dispone de nueva evidencia y se completa nuestro proceso de
revisión por pares .

Revisión de la literatura vigente hasta:  marzo de 2023. | Última actualización de este tema:  06 de marzo de
2023.

INTRODUCCIÓN

La hernia de hiato es un hallazgo frecuente tanto por radiólogos ( imagen 1 ) como por
gastroenterólogos. Sin embargo, las estimaciones de la prevalencia de la hernia de hiato
varían ampliamente debido a las inconsistencias en la identificación de pequeñas hernias de
hiato por deslizamiento. También existe confusión con respecto a la función normal de la
unión gastroesofágica y las implicaciones clínicas de una hernia de hiato.

Este tema revisará la fisiopatología, la clasificación, las manifestaciones clínicas, el

diagnóstico y el tratamiento de una hernia de hiato. El manejo quirúrgico de la hernia
paraesofágica y el manejo de la enfermedad por reflujo gastroesofágico se analizan por
separado. (Consulte "Manejo quirúrgico de la hernia paraesofágica" y "Manejo médico de la
enfermedad por reflujo gastroesofágico en adultos" y "Enfoque de la enfermedad por reflujo
gastroesofágico refractaria en adultos" .)

ANATOMÍA Y FISIOLOGÍA DE LA UNIÓN ESOFAGOGÁSTRICA

El extremo distal del esófago está anclado al diafragma por la membrana frenoesofágica,
formada por las fascias endotorácica y endoabdominal fusionadas. Esta membrana elástica
se inserta circunferencialmente en la musculatura esofágica, muy cerca de la unión
escamocolumnar, que reside dentro del hiato diafragmático.

Esta configuración se altera durante el peristaltismo iniciado por la deglución, una

contracción secuenciada del músculo longitudinal y circular responsable de la propulsión del
bolo a través del esófago [ 1 ]. Con la contracción del músculo longitudinal esofágico, el
esófago se acorta y la membrana frenoesofágica se estira; su retroceso elástico es entonces
responsable de llevar la unión escamocolumnar a su posición normal después de cada
deglución. Esto es, en efecto, una "hernia fisiológica", ya que el cardias gástrico atraviesa el
hiato diafragmático con cada deglución ( figura 1 ) [ 2 ].

La estructura globular que se observa en las radiografías y que se forma por encima del
diafragma y por debajo del esófago tubular durante el peristaltismo se denomina ampolla
frénica; está limitado por arriba por el esófago distal y por abajo por el diafragma crural (
figura 2 ) [ 3 ]. Fisiológicamente, la ampolla frénica es el esfínter esofágico inferior (EEI)
relajado, borrado y alargado [ 4 ]. El vaciado de la ampolla se produce entre inspiraciones
junto con el alargamiento del esófago y la contracción del EEI [ 4,5 ].

El estrés repetitivo de la deglución, así como el asociado con el esfuerzo abdominal y los
episodios de vómitos, someten a la membrana frenoesofágica a un desgaste considerable, lo
que la convierte en un objetivo plausible de la degeneración relacionada con la edad. Otra
fuente potencial de estrés en la membrana frenoesofágica es la contracción tónica del
músculo esofágico longitudinal inducida por el reflujo gastroesofágico y la acidificación de la
mucosa [ 6 ].

Aparte de su función de propulsión anterógrada, la unión esofagogástrica (UEG) también

sirve para minimizar el reflujo. Esto se logra mediante un mecanismo valvular complejo, cuya
función se atribuye en parte al esófago, en parte al estómago y en parte al diafragma crural
[7 ] . El elemento esofágico se ha analizado extensamente y consiste en el LES, un segmento
de 2 cm de músculo liso contraído tónicamente.

● El margen proximal del EEI se extiende hasta una distancia corta proximal a la unión
escamocolumnar.

● El margen distal del EEI es más difícil de definir, pero meticulosas reconstrucciones
tridimensionales sugieren que el músculo "circular" del EEI es en realidad un par de
 espirales opuestas que terminan cuando las fibras del cabestrillo gástrico crean una
mioarquitectura similar a una soga en el EGJ y establecer el ángulo de His ( figura 3 )
[ 8 ].

● Rodeando el EEI al nivel de la unión escamocolumnar se encuentra el diafragma crural,

compuesto principalmente por el pilar diafragmático derecho [ 8 ].

Los estudios fisiológicos han demostrado que la contracción diafragmática aumenta la

presión de la UEG, en esencia sirviendo como un esfínter externo [ 9 ]. Además, si la UEG se
define como el final del EEI o el punto en el que el esófago tubular se une al estómago
sacular, normalmente hay unos 2 cm de esófago tubular dentro del abdomen [10 ] .

DEFINICIÓN

La hernia de hiato se refiere a la herniación de elementos de la cavidad abdominal a través

del hiato esofágico del diafragma.

CLASIFICACIÓN

Las hernias de hiato se dividen ampliamente en hernias deslizantes y paraesofágicas (

figura 4 e imagen 2 ). El esquema de clasificación más completo reconoce cuatro tipos
de hernia de hiato.

Tipo I: hernia deslizante  :  una hernia de hiato deslizante o tipo I se caracteriza por el
desplazamiento de la unión esofagogástrica (UEG) por encima del diafragma. El estómago
permanece en su alineación longitudinal habitual y el fundus permanece por debajo de la
UEG.

Tipo II, III, IV: hernias paraesofágicas  :  una hernia paraesofágica es una hernia verdadera
con un saco herniario compuesto de peritoneo y caracterizada por una dislocación hacia
arriba del fondo gástrico a través de un defecto focal en la membrana frenoesofágica [ 11 ] .

● La hernia tipo II resulta de un defecto localizado en la membrana frenoesofágica donde

el fondo gástrico sirve como punto de entrada de la hernia, mientras que la UEG
permanece fija a la fascia preaórtica y al ligamento arcuato medio (figura 4) [ 12 ] .
 ● Las hernias de tipo III tienen elementos de las hernias de tipo I y II y se caracterizan por
la hernia de la UEG y el fondo a través del hiato. El fondo se encuentra por encima de la
UEG ( imagen 3 ).

● La hernia de hiato tipo IV se asocia con un gran defecto en la membrana frenoesofágica

y se caracteriza por la presencia de órganos distintos del estómago en el saco herniario
(p. ej., colon, bazo, páncreas o intestino delgado) (imagen 4 ).

EPIDEMIOLOGÍA

It is estimated that greater than 95 percent of hiatus hernias are type I (sliding), with type II,
III, and IV (paraesophageal) hernias accounting for approximately 5 percent [13]. Of the
paraesophageal hernias, it is estimated that more than 90 percent are type III and the least
prevalent are type II. Estimates of prevalence of a type I hiatus hernia in the adult population
in North America vary widely from 10 to 80 percent, largely because of inconsistencies in
distinguishing a small sliding hernia from a "generous" phrenic ampulla.

ETIOLOGY

Although the etiology of most hiatal hernias is speculative, trauma, congenital malformation,
and iatrogenic factors have been implicated in some patients with a type I (sliding) hiatus
hernia. Type II, III, and IV (paraesophageal) hernias are a recognized complication of surgical
dissection of the hiatus and occur during antireflux procedures, esophagomyotomy, or
partial gastrectomy.

PATHOPHYSIOLOGY

Type I: Sliding hernia — Type I hiatus hernia results from progressive disruption of the
esophagogastric junction (EGJ), first with loss of the intra-abdominal length of the
esophagus, then with progressive widening of the hiatus and herniation of the gastric cardia
[14,15]. Widening of the muscular hiatus and circumferential laxity of the phrenoesophageal
membrane allows a portion of the gastric cardia to herniate upward [15]. A sliding hernia
does not have a hernia sac and slides into the chest since the EGJ is not fixed inside the
abdomen. The phrenoesophageal membrane remains intact, albeit stretched, and the hernia
is contained within the posterior mediastinum ( figure 4 and image 2).

● Mechanism of gastroesophageal reflux in type I hiatus hernia — Endoscopic and

radiographic studies suggest that 50 to 94 percent of patients with gastroesophageal
reflux disease (GERD) have a type I hiatus hernia as compared with 13 to 59 percent of
individuals without GERD [13,16]. The likelihood of GERD increases with anatomic
compromise of the EGJ and size of the hiatal hernia. Type I hiatus hernia impacts on
reflux both by affecting the competence of the EGJ in preventing reflux and in
compromising the process of esophageal acid clearance once reflux has occurred. (See
"Pathophysiology of reflux esophagitis".)

● EGJ competence – A key function of the EGJ is to limit the reflux of gastric contents,
including gastric acid, into the esophagus. Some degree of reflux is necessary to
facilitate gas venting (belching) and vomiting, but with EGJ incompetence there is
excessive reflux of gastric acid into the esophagus leading to reflux symptoms and/or
reflux esophagitis. EGJ incompetence is attributable to both anatomical and physiologic
factors. The key physiologic factor is lower esophageal sphincter (LES) hypotension. The
key anatomic factor is the degradation of the EGJ. This is associated with loss of the
intra-abdominal segment of the esophagus, which widens the angle of His and disables
the "flap valve" mechanism wherein increased intragastric pressure compresses the
subdiaphragmatic segment of esophagus preventing reflux [14]. With further EGJ
degradation there is dilatation of the diaphragmatic hiatus, which diminishes its
"pinchcock" action of crimping closed and angulating the esophagus with inspiration,
abdominal straining, or coughing [8,17-19]. Hiatal dilatation also increases the
compliance of the LES, leading to greater opening diameters such that gas venting
events are often accompanied by gastric acid reflux and the overall volume of reflux
increases [20]. Finally, with overt hiatus hernia, the diaphragmatic contribution to EGJ
competence is completely disabled, now relying entirely on the LES itself [10]. Thus,
although neither hiatus hernia nor a hypotensive LES alone results in severe EGJ
incompetence, the two conditions interact with each other. This conclusion is consistent
with the clinical observation that exercise, tight-fitting garments, and activities involving
bending at the waist exacerbate heartburn, especially after having consumed meals
that reduce LES pressure. (See "Pathophysiology of reflux esophagitis".)
 ● Compromise of esophageal emptying – Patients with type I hiatus hernia have
prolongation in acid clearance especially while recumbent. The hiatus hernia
compromises fluid emptying from the distal esophagus by "re-reflux" from the hernia
compartment during swallowing ( figure 5) [21,22]. Re-reflux occurs predominantly
during inspiration and can be attributed to loss of the normal one-way valve function of
the crural diaphragm. By pinching off the distal esophagus, the crural diaphragm
prevents backward flow from the stomach during each inspiration when it would be
favored by a positive abdominal-thoracic pressure gradient. This one-way valve function
of the crural diaphragm is grossly impaired with large type I hernias because a gastric
pouch persists above the diaphragm [21].

Type II, III, and IV: Paraesophageal hernias — While it is unclear if this is either a cause or
effect, paraesophageal hernias are associated with abnormal laxity of the gastrosplenic and
gastrocolic ligaments, which normally prevent displacement of the stomach. As the hernia
enlarges, the greater curvature of the stomach rolls up into the thorax. Because the stomach
is fixed at the EGJ, the herniated stomach tends to rotate around its longitudinal axis,
resulting in an organoaxial volvulus ( figure 6) [23]. Infrequently, rotation occurs around
the transverse axis, resulting in a mesenteroaxial volvulus [23]. Over time, the entire stomach
can eventually herniate, with the pylorus juxtaposed to the gastric cardia, forming an upside-
down, intrathoracic stomach.

CLINICAL FEATURES

Clinical manifestations — Type I (sliding) hiatal hernias are often asymptomatic or

associated with symptoms of gastroesophageal reflux disease (GERD), the most common of
which are heartburn, regurgitation, and dysphagia. (See "Clinical manifestations and
diagnosis of gastroesophageal reflux in adults", section on 'Clinical manifestations'.)

Complications are rare in patients with type I hiatal hernia and are usually related to reflux
esophagitis (see "Complications of gastroesophageal reflux in adults"). However, large type I
hernias can be associated with Cameron lesions, which appear as linear erosions at the level
of the hiatus and are a cause of iron deficiency anemia [24].

Patients with type II, III, and IV (paraesophageal) hernias can be asymptomatic or have only
vague, intermittent symptoms [11]. The most common symptoms are epigastric or
substernal pain, postprandial fullness, nausea, and retching. GERD symptoms are less
prevalent as compared with patients with a type I hernia.

Most complications of a paraesophageal hernia are due to mechanical problems caused by

the hernia and include the following:

● Gastric volvulus can occur with large paraesophageal hernias, causing dysphagia,
postprandial pain, ischemia, and (rarely) strangulation.

● Bleeding, although infrequent, occurs from gastric ulceration, gastritis, or erosions

within the incarcerated hernia pouch.

● Dyspnea can result from limited lung expansion because of a large part of the stomach
or other organs herniating through the hiatus.

Radiographic findings — In patients with paraesophageal hernias, an upright radiograph,

computed tomography (CT) scan, or magnetic resonance imaging (MRI) of the chest may
reveal a retrocardiac air-fluid level within a paraesophageal hernia or intrathoracic stomach
( image 1 and image 5). In type IV paraesophageal hernia, other organs within the
hernia sac can be identified on CT or MRI of the chest ( image 4).

DIAGNOSIS

A type I (sliding) hiatus hernia is suspected in patients with symptoms of gastroesophageal

reflux disease (GERD) including heartburn, regurgitation, and dysphagia. A type II, III and IV
(paraesophageal) hernia is suspected in patients with a history of surgical dissection of the
hiatus (eg, antireflux procedures, esophagomyotomy, or partial gastrectomy) and epigastric
or substernal pain or fullness, nausea, or vomiting. However, hiatus hernia is usually
diagnosed incidentally on upper endoscopy, manometry, or imaging studies done for other
reasons. (See 'Radiographic findings' above and "Approach to the evaluation of dysphagia in
adults", section on 'Symptom-based differential diagnosis' and "Clinical manifestations and
diagnosis of gastroesophageal reflux in adults", section on 'Differential diagnosis'.)

Paraesophageal hernias may be diagnosed on an upper endoscopy, but barium swallow is

the most sensitive diagnostic test.
 ● Sliding hiatal hernias that are larger than 2 cm in axial span can be diagnosed by
barium swallow, endoscopy, or esophageal manometry. In contrast, small sliding hiatus
hernias can only be diagnosed with certainty during surgery [25].

Upper endoscopy and barium swallow are unreliable for defining smaller sliding hiatus
hernias as the esophagogastric junction (EGJ) is highly mobile and because of the lack
of standardization as to when the size of hiatus hernia should be measured with
respect to peristalsis and the extent of gastric distention. Only when a sliding hiatal
hernia is >2 cm is its presence obvious because gastric folds are evident traversing the
diaphragm both during swallow-induced esophageal shortening and at rest
( image 6).

Barium swallow — Barium swallow can determine the anatomy and size of the hernia,
orientation of the stomach, and location of the EGJ ( image 2). A sliding hiatus hernia is
characterized by a greater than 2-cm separation between the mucosal B ring at the site of
the squamocolumnar junction and the diaphragmatic hiatus ( figure 2). If a B ring is not
evident on barium swallow, the demonstration of at least three rugal folds traversing the
diaphragm is diagnostic of a sliding hiatus hernia ( image 6).

Visualization of a portion of the gastric fundus herniating along the distal esophagus on
barium swallow is diagnostic of a paraesophageal hernia ( image 7).

Upper endoscopy — On upper endoscopy, the axial length of a sliding hiatus hernia is
measured by the degree of separation between the squamocolumnar junction and the
diaphragmatic impression from a retroflexed view after distending the stomach and even
tugging along the lesser curve to elicit herniation ( picture 1) [15].

In patients with a paraesophageal hernia, retroflexed view on upper endoscopy shows a

portion of the stomach herniating upward through the diaphragm adjacent to the
endoscope.

High-resolution manometry — On high-resolution manometry (HRM), a hiatus hernia is

characterized by the spatial separation between the crural diaphragm (CD) and lower
esophageal sphincter (LES) [12,25]. It also allows for prolonged observation that enables the
identification of intermittent herniation ( figure 7). Small sliding hiatus hernias with less
than 2 cm separation between the LES and CD often reduce spontaneously during prolonged
manometric recordings (see "High resolution manometry", section on 'Anatomic sphincters').
An analysis comparing the accuracy of HRM, endoscopy, and barium radiography to surgery
in detecting and sizing hiatus hernia [26] concluded that HRM, using the LES-CD separation
metric, outperformed the other modalities with a sensitivity of 94 percent, specificity of 92
percent, and kappa value of 0.85. In that analysis, HRM reached both optimal sensitivity and
specificity for detecting hiatus hernia, with a threshold LES–CD separation of 1.2 cm.
Furthermore, as the LES and CD become spatially separate, there is the added issue of
whether the respiratory inversion point (RIP), the locus at which the inspiratory effect on
intraluminal pressure transitions from augmentation (characteristic of the abdomen) to a
reduction (characteristic of the chest), remains in its native position above the LES or not.
Although the precise physiologic meaning of the RIP is uncertain and its localization
sometimes challenging, there can be general agreement that: the RIP can never be below
the diaphragm; when the CD is superimposed on the LES, the RIP localizes above the EGJ
pressure complex, placing the LES physiologically within and beneath the diaphragmatic
hiatus; and with spatial separation of the CD and LES, the RIP can localize either at or above
the CD component, placing it either within the hernia or at the LES ( figure 7) [27].

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of hiatus hernia includes other etiologies of epigastric or

substernal pain, dysphagia, heartburn or regurgitation, and refractory gastroesophageal
reflux disease. This includes esophagitis, an esophageal motility disorder, functional
dyspepsia, and coronary artery disease. While an evaluation to exclude these diagnoses is
not required to diagnose a hiatus hernia, it may be necessary in patients with refractory
symptoms and is discussed in detail, separately. (See "Clinical manifestations and diagnosis
of gastroesophageal reflux in adults", section on 'Evaluation in selected patients'.)

MANAGEMENT

Sliding hiatus hernia — Surgical repair of an asymptomatic type I hiatal hernia is not

indicated. Management of patients with a symptomatic sliding hiatus hernia consists of
management of gastroesophageal reflux disease (GERD). Medical management of GERD and
the role of surgery in the management of GERD are discussed separately. (See "Medical
management of gastroesophageal reflux disease in adults" and "Surgical management of
gastroesophageal reflux in adults".)

Paraesophageal hernia — The optimal management of asymptomatic patients with

paraesophageal hernias is controversial [28]. While a few experts recommend prophylactic
surgical treatment even in the absence of symptoms, most experts advocate against it as the
annual risk of developing acute symptoms requiring emergent surgery is less than 2 percent
and the mortality rate from elective paraesophageal hernia repair is approximately 1.4
percent [29,30].

Surgical repair is indicated in patients with a symptomatic paraesophageal hernia [29].

Emergent repair is required in patients with a gastric volvulus, uncontrolled bleeding,
obstruction, strangulation, perforation, and respiratory compromise secondary to a
paraesophageal hernia [11,28,30-32]. The indications for surgical repair, preoperative
evaluation, and the technical aspects of surgical repair of paraesophageal hernias are
discussed in detail, separately. (See "Medical management of gastroesophageal reflux
disease in adults", section on 'Initial management' and "Surgical management of
paraesophageal hernia", section on 'Indications for surgical repair'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Hiatal hernia".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have
about a given condition. These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th
grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles on
a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Hiatal hernia (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Definition – Hiatus hernia refers to herniation of elements of the abdominal cavity

through the esophageal hiatus of the diaphragm. (See 'Definition' above.)

● Classification – Hiatus hernias are broadly divided into sliding and paraesophageal
hernias ( figure 4 and image 2). A type I or sliding hiatus hernia is characterized by
the displacement of the esophagogastric junction (EGJ) above the diaphragm. The
stomach remains in its usual longitudinal alignment and the fundus remains below the
EGJ. Type II, III, and IV hiatus hernias or paraesophageal hernias are characterized by
an upward dislocation of the gastric fundus. Approximately 95 percent of all hiatus
hernias are sliding and 5 percent are paraesophageal. (See 'Classification' above and
'Epidemiology' above.)

● Etiology – Although the etiology of most hiatus hernias is speculative, trauma,

congenital malformation, and iatrogenic factors have been implicated in some patients
with sliding hiatus hernias. Paraesophageal hernias are a recognized complication of
surgical dissection of the hiatus. (See 'Etiology' above.)

● Pathophysiology – A sliding hiatus hernia results from progressive disruption of the

EGJ that allows a portion of the gastric cardia to herniate upward ( figure 8). In
contrast, paraesophageal hernias are associated with abnormal laxity of the
gastrosplenic and gastrocolic ligaments, which allows the greater curvature of the
stomach to roll up into the thorax. (See 'Pathophysiology' above.)

● Clinical features – Most small sliding hiatus hernias are asymptomatic. Patients with
large sliding hiatus hernias may have symptoms of gastroesophageal reflux disease
(GERD). Many patients with paraesophageal hernias are either asymptomatic or have
only vague, intermittent symptoms of epigastric or substernal pain or postprandial
 fullness, nausea, and retching. In patients with paraesophageal hernias, an upright
radiograph, computed tomography (CT) scan, or magnetic resonance imaging (MRI) of
the chest may reveal a retrocardiac air-fluid level within a paraesophageal hernia or
intrathoracic stomach ( image 1 and image 5 and image 4). (See 'Clinical
features' above.)

● Diagnosis – Hiatus hernia is usually discovered incidentally on upper endoscopy,

manometry, or imaging done for other reasons or during a work-up for GERD.
Paraesophageal hernias may be diagnosed on an upper endoscopy, but barium
swallow is the most sensitive diagnostic test. Sliding hiatal hernias that are larger than 2
cm in axial span can be diagnosed by barium swallow, endoscopy, or esophageal
manometry, but smaller sliding hernias are often only detected during surgery. (See
'Diagnosis' above.)

● Management

• Sliding hiatus hernia – Repair of an asymptomatic sliding hiatus hernia is not

indicated. Management of patients with a symptomatic sliding hiatus hernia consists
of management of GERD. (See 'Management' above and "Medical management of
gastroesophageal reflux disease in adults" and "Approach to refractory
gastroesophageal reflux disease in adults" and "Surgical management of
gastroesophageal reflux in adults".)

• Paraesophageal hernia – Surgical repair for paraesophageal hernias is reserved for

symptomatic patients and for management of complications (eg, gastric volvulus,
bleeding, obstruction, strangulation, perforation, and respiratory compromise
secondary to a paraesophageal hernia). (See 'Clinical manifestations' above and
'Management' above and "Surgical management of paraesophageal hernia", section
on 'Indications for surgical repair'.)

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Topic 2259 Version 24.0

GRAPHICS

Incidental finding of a hiatus hernia on chest x-ray

and CT scan

The A-P chest x-ray (A) shows a hiatus hernia (asterisk) with an air
fluid level (arrows). A lateral chest x-ray (B) confirms a hiatus hernia
(asterisk) and an air fluid level in the hernia (arrows). A CT scan in
the axial plane (C) shows contrast in the hiatus hernia (asterisk).

A-P: anteroposterior; CT: computed tomography.

Graphic 90295 Version 2.0

Esophageal shortening during swallow

(A) Before swallow - Clip B marks the position of the

squamocolumnar junction (SCJ), 35 mm distal to the anchor point on
the vertebral body; clip A is affixed to the esophageal mucosa 31
mm proximally. Clip movements are referenced to point V on the
vertebral column.
(B) At the time of maximal esophageal shortening during swallow,
clip B is 20 mm distal to point V and the distance between clips A
and B is reduced to 22 mm, indicative of 29 percent shortening.
(C) As elongation proceeds, first both clips descend, after which clip
B descends, stretching the A-B segment back to its initial length.
(D) After swallow recovery to normal.

With permission from: Kahrilas PJ, Wu S, Lin S, et al. Attenuation of esophageal

shortening during peristalsis with hiatus hernia. Gastroenterology 1995; 109:1818.

Graphic 61193 Version 4.0

Anatomic features of sliding hiatus hernia

Representation of the anatomic features of a sliding hiatus hernia

viewed radiographically during swallowing. The "A" ring is a
muscular ring visible during swallowing which demarcates the
superior margin of the lower esophageal sphincter. The "B" ring at
the squamocolumnar junction is present in only about 15 percent of
individuals; it permits accurate division of the phrenic ampulla into
the esophageal vestibule (A ring to B ring) and the sliding hiatus
hernia (B ring to the subdiaphragmatic stomach). Rugal folds
traversing the hiatus support the conviction that a portion of the
stomach is supradiaphragmatic.

Reproduced with permission from: Kahrilas PJ. Hiatus hernia causes reflux: Fact or
fiction? Gullet 1993; 3(Suppl):21.

Graphic 72582 Version 4.0

Three-dimensional myoarchitecture of the LES

Three-dimensional myoarchitecture of the LES using optical sectioning microscopy and computer reconstructi
bloc resection from young human cadaver.

LES: lower esophageal sphincter.

From: Zifan A, Kumar D, Cheng LK, Mittal RK. Three-dimensional myoarchitecture of the lower esophageal sphincter and esophageal hia
using optical sectioning microscopy. Sci Rep 2017; 7:13188. Copyright © 2017 The Authors. Available at: www.nature.com/articles/s4159
13342-y (Accessed on January 18, 2023). Reproduced under the terms of the Creative Commons Attribution License 4.0.

Graphic 140575 Version 1.0

Sliding versus paraesophageal hiatus hernia

Distinction between a sliding hiatus hernia (type I) and paraesophageal hernia

(type II). With type I hernia, the leading edge is the gastric cardia while with
type II it is the gastric fundus. The squamocolumnar junction maintains its
native position in the paraesophageal hernia while it is displaced upward with
the sliding hernia.
SC: squamocolumnar.

Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best
Pract Res Clin Gastroenterol 2008; 22:601.

Graphic 62190 Version 5.0

Barium swallow in a patient with a hiatus hernia

(A) Normal barium swallow showing the gastroesophageal junction

(arrow) is at the level of the diaphragm (arrowhead) and the gastric
folds (dashed arrow) are at the same level as the diaphragm.
(B) Barium swallow showing a sliding hiatus hernia (asterisk). The
gastroesophageal junction (arrow) is above the diaphragm
(arrowhead) and the gastric folds (dashed arrow) are above the
diaphragm.
(C) Barium swallow showing a paraesophageal hernia (asterisk). The
gastroesophageal junction (arrow) is below the diaphragm
(arrowhead).
Graphic 90296 Version 2.0
Barium swallow in a patient with a type III paraesophageal hernia

(A) A chest x-ray prior to contrast administration shows the nasogastric tube coiled in the
chest (arrows).
(B) Following barium administration through the nasogastric tube, the gastroesophageal
junction and the entire stomach are noted within the chest.

Graphic 90299 Version 2.0

Barium swallow and computed tomography (CT) scan in a patient
with a type IV paraesophageal hiatus hernia

(A) A barium swallow showing the entire stomach within the chest (asterisk). The
gastroesophageal junction (arrow) is above the diaphragm (arrowhead) and the first part
of the duodenum (dashed arrow) is at the level of the diaphragm.
(B) A CT scan through the lower chest showing the herniated stomach (asterisk) and
portions of the colon within the hernial sac in the chest (arrow).

Graphic 90300 Version 2.0

Rereflux with hiatus hernia

Depiction of a radionuclide acid clearance study in a subject with a

hiatus hernia. Fifteen seconds after the injection of a 15 mL bolus of
0.1 N HCl labeled with 200 microcuries of 99mTc-sulfur colloid,
subjects swallowed every 30 seconds. The vertical axis represents
the region from the sternal notch to the stomach. The horizontal
axis is the time scale. The radioactivity is represented by the black
area and no radioactivity is represented by the absence of black
color. Soon after injection, the radioactivity appears in the stomach.
However, there is reflux of isotope into the esophagus followed by
clearance of the isotope during each of the first three swallows.

Reprinted with permission from: Mittal RK, Lange RC, McCallum RW. Identification
and mechanism of delayed esophageal acid clearance in subjects with hiatus hernia.
Gastroenterology 1987; 92:130. Copyright 1987 by American Gastroenterological
Association. This material may not be reproduced or distributed in any form or by
any means without the proper written permission of the publisher.

Graphic 72024 Version 5.0

Volvulus in hiatus hernia

Paraesophageal hernias are associated with abnormal laxity of

structures normally preventing displacement of the stomach, the
gastrosplenic and gastrocolic ligaments. As the hernia enlarges, the
greater curvature of the stomach rolls up into the thorax. Because
the stomach is fixed at the gastroesophageal junction, the herniated
stomach tends to rotate around its longitudinal axis, resulting in an
organoaxial volvulus (top panels); infrequently, rotation occurs
around the transverse axis resulting in a mesenteroaxial volvulus
(bottom panels).

Adapted from: Peridikis G, Hinder RA. Paraesophageal hiatal hernia. In: Hernia,
Nyhus LM, Condon RE (Eds), JB Lippincott, Philadelphia 1995. p.544.

Graphic 73205 Version 4.0

Barium swallow and computed tomography (CT) scan in a patient
with a paraesophageal hernia

(A) A barium swallow showing a paraesophageal hernia (asterisk). The gastroesophageal

junction (arrow) is at the level of the diaphragm (arrowhead).
(B) An axial CT scan through the lower chest showing the region of the gastroesophageal
junction (arrow) at the level of the diaphragm (arrowhead) with a paraesophageal hernia
(asterisk).

Graphic 90298 Version 2.0

Barium swallow in a patient with a sliding hiatus
hernia

A barium swallow shows a moderate sized sliding hiatus hernia

(asterisk) above the diaphragm (arrowhead), with well-defined
gastric folds (arrow).

Graphic 90297 Version 2.0

Barium swallow of a large paraesophageal hernia

Barium swallow of a paraesophageal hernia. Note that as the herniated stomach

enlarges, it inverts and twists causing a volvulus. In the extreme, this results in
an upside-down stomach. The esophagus is not seen in this image, but if the
gastroesophageal junction is at the level of the diaphragm, this would be a type
II (paraesophageal) hernia. More commonly, it is above the diaphragm, which
makes it a type III (paraesophageal) hernia.

Graphic 93824 Version 1.0

Endoscopic image of a type I sliding hiatus hernia

Retroflexed (A) and forward-looking (B) endoscopic views of a sliding (type I)

hiatus hernia. The squamocolumnar junction (SCJ) marks the distal limit of
the esophageal epithelium. Distal to the SCJ is the constriction of the
diaphragmatic hiatus.

Graphic 93823 Version 1.0

High Resolution Manometry (HRM) recording of esophagogastric juncti
on (EGJ) pressure
Panel A: High resolution manometry (HRM) recording of esophagogastric junction (EGJ)
pressure in an individual without a hiatal hernia as evident by the crural diaphragm (CD) being
completely superimposed on the lower esophageal sphincter (LES) pressure signature, ie, the
LES-CD separation is 0. Both during quiet respiration and deep breaths, the LES is only evident
between inspirations when the CD signal is minimal. In this example, the pressure inversion
point (PIP) tool has been positioned to optimally isolate the respiratory inversion point (RIP) as
evident by the PIP tool output shown as an insert. Barely visible on the pressure topography
are a horizontal blue dashed line and green dashed line indicating the locations of the
proximal and distal pressure (P) recordings shown in the PIP tool output. The red line in the
PIP tool output box is the computed average of those signals. In using the tool, the area of
interrogation is scrolled up and down to find the location at which the red line in the PIP tool
output box is most nearly flat, indicative of the site at which the respiratory increases in
pressure are offset by the respiratory decreases in pressure seen on the blue line. The area of
interest is during quiet respiration and the RIP is seen to localize toward the upper margin of
the CD signal. This positions the majority of the LES signal within the hiatus, being pulled
downward during the three deep breaths.
Panel B: HRM recording of EGJ pressure in an individual with a small hiatal hernia as evident by
the CD being only partially superimposed on the LES pressure signature, ie, the LES-CD
separation is 2 cm. Formatting of the figure is identical to that of Panel A, with the dominant
EGJ pressure profile highlighted by the black line (the 15 mmHg isobaric contour) and the PIP
tool optimally positioned to isolate the RIP. Note how the LES-CD separation is measured. The
center of the LES and CD high pressure zones (white and black horizontal arrows, respectively)
are isolated with the help of the isobaric contour tool (set at 15 mmHg in this example), and
the separation between the two rounded off to the nearest cm. In this example, the RIP
continues to localize toward the upper margin of the CD signal, implying that the CD still
exerts sufficient sphincteric effect such that it closes the lumen isolating the stomach below
from the hernia and LES above. This is particularly evident during the three deep breaths
where the strongly negative intrathoracic pressure (deep blue) is seen to abut directly on the
CD-apex signal.
Panel C: HRM recording of EGJ pressure in an individual with a moderate-sized hiatal hernia as
evident by the CD being isolated from the LES pressure signature, ie, the LES-CD separation is
4 cm. Formatting of the figure is identical to that of Panels A and B, with the dominant EGJ
pressure profile highlighted by the black line (the 25 mmHg isobaric contour in this case) and
the PIP tool optimally positioned to isolate the RIP. However, in this example, the RIP no longer
localizes the CD signal, instead localizing at the proximal margin of the LES. Even without the
aid of the PIP tool, that is evident by the inspiratory bursts of red on the LES recording.
Consequently, the CD no longer functions as a competent extrinsic sphincter, and the entire
hiatal hernia up to the lower margin of the LES is subject to intra-gastric pressure throughout
the respiratory cycle.

Reproduced with permission from: the Esophageal Center at Northwestern. Copyright © 2020 Northwestern
University. All rights reserved.

Graphic 129815 Version 1.0

Progressive anatomic disruption of the
gastroesophageal junction

Endoscopic appearance and corresponding three-dimensional

representation of the progressive anatomic disruption of the
gastroesophageal junction as occurs with development of a type I
hiatus hernia. In the grade I configuration, a ridge of muscular
tissue is closely approximated to the shaft of the retroflexed
endoscope. With a grade II configuration the ridge of tissue is
slightly less well defined and there has been slight orad
displacement of the squamocolumnar junction along with widening
of the angle of His. In the grade III appearance the ridge of tissue at
the gastric entryway is barely present and there is often incomplete
luminal closure around the endoscope. Note, however, that this is
not a hiatal hernia because the squamocolumnar junction is not
displaced axially in the endoscopic photograph. With grade IV
deformity, no muscular ridge is present at the gastric entry. The
gastroesophageal area stays open all the time, and squamous
epithelium of the distal oesophagus can be seen from the
retroflexed endoscopic view. A hiatus hernia is always present with
grade IV deformity.

Reproduced from: Bredenoord AJ, Pandolfino JE, Smout AJ. Gastro-oesophageal

reflux disease. Lancet 2013; 381:1933. Illustration used with the permission of
Elsevier Inc. All rights reserved.

Graphic 85907 Version 1.0