What is a hiatal hernia?
Sliding hiatal hernia
Paraesophageal and Mixed type of hiatal hernia
Diagnosis
Treatment
Additional Info

What is a hiatal hernia?
The abdomen and chest are separated by a dome shaped muscle called the diaphragm. The esophagus passes through an opening (the hiatus) in the diaphragm to connect to the stomach. When the upper stomach bulges through this opening this is called a hiatal hernia. There are 3 main types of hiatal hernia: sliding, paraesophageal, and mixed. For many patients and doctors the term hiatal hernia is used to mean Acid Reflux (or GERD). This is NOT correct. There are many patients with severe acid reflux who do not have hiatal hernia, and many patients with large hiatal hernia that do not have acid reflux. It is true that having a hiatal hernia increase the risk of having significant GERD. When GERD is treated surgically in patients who also have a hiatal hernia, the hernia is fixed as part of the surgical procedure.

Sliding hiatal hernia
In a sliding hiatal hernia, part of the stomach moves through the diaphragm so that it is positioned outside of the abdomen and in the chest. The lower esophageal sphincter (LES) often moves up above its normal location in the opening of the diaphragm.

Sliding hiatal hernia is by far the most common type of hiatal hernia, and other then its association with acid reflux, usually does not require repair except in conjunction with anti-reflux surgery.

Paraesophageal hernia and Mixed Hernia
In a paraesophageal hernia, the stomach bulges up through the opening in the diaphragm (hiatus) alongside the esophagus (upside-down stomach). The LES remains in its normal location inside the opening of the diaphragm. This type of hernia most commonly occurs when there is a large opening in the diaphragm next to the esophagus.

The stomach and, rarely, other abdominal organs (such as the intestine, spleen, and colon) may also bulge into the chest in a paraesophageal hernia.

In a mixed hiatal hernia, the LES is above the diaphragm as in a sliding hiatal hernia, and the stomach is alongside the esophagus as in a paraesophageal hiatal hernia.

Paraesophageal and mixed hiatal hernias often have no symptoms or only minimal symptoms. Symptoms may include vague, nonspecific abdominal complaints such as feeling full after a meal and indigestion. Patients may also have vomiting or chest pain. Occasionally patients have minimal symptoms but have anemia that is difficult to explain. This is due to very slow loss of blood from irritation of the stomach at the neck of the hernia.

If not treated, the Paraesophageal and mixed hernias can grow. This can result in twisting (volvulus) of the stomach (possibly leading to gangrene), which requires emergency surgical treatment. Because of the risk involved in emergency treatment, it generally is recommended that all people with these types of hernias undergo surgery regardless of the symptoms.

Diagnosis

• Barium swallow — This is an X-ray test that outlines the esophagus. This test is fairly accurate at diagnosing paraesophageal hernias, but is somewhat less reliable in diagnosing sliding hernia.
  
• Endoscopy — Used to check the inner lining of the stomach. Somewhat inaccurate in confirming sliding hernia.
• Esophageal manometry or motility studies — These studies can measure how tightly the LES shuts, and they can also check for abnormalities in esophageal pressure and movement.
  
• Cardiac evaluation — Patients who have chest pain as a GERD symptom may also need an electrocardiogram (called ECG or EKG) and an exercise stress test to rule out heart disease.
• Esophageal pH monitoring — This test uses electrodes to measure the pH (acid level) in the esophagus, usually over a 24-hour period.
• Abdominal ultrasound — Uses sound waves to image the abdominal organs to look for other abnormalities that account for your symptoms including gallbladder problems.

Treatment
Sliding hernias usually do not need to be treated except in conjunction with surgical treatment of acid reflux.

If left untreated, paraesophageal and mixed hernias can develop serious complications including strangulation and perforation of the stomach. Because of this, when paraesophageal hernias are identified, repair of the hernia is recommended in most patients.

Paraesophageal Hernia Repair is usually done laparoscopically, and for patients with significant GERD is sometimes combined with a Nissen Fundoplication to prevent future reflux.

Additional Info (links)
Society of Laparoendoscopic Surgeons: General info about GERD
Society of American Gastrointestinal Endoscopic Surgeons: General info about GERD
Society of American Gastrointestinal Endoscopic Surgeons: Guidelines for the treatment of GERD
Stretta Procedure: General GERD info along with info about Stretta
News article from Arizona describing the Stretta procedure
Jackson Gastroenterology: Good illustration
GERD diet
American Gastroenterological Association : General info about GERD
GERD information resource center: May be a bit technical for some patients but some nice animations demonstrating GERD
National Digestive Disease Clearinghouse: General info
Heartburn Help Website: Site sponsored by Ethicon