Hiatal hernia: key principles for a rarely encountered condition

Abstract

Hiatal hernia is a prevalent condition characterized by the herniation of abdominal contents, most commonly the stomach, through the esophageal hiatus of the diaphragm into the thoracic cavity. It is traditionally classified into the following 4 types: type I is associated with displacement of the gastroesophageal junction (GEJ) and is often linked to gastroesophageal reflux disease; type II, in which the gastric fundus herniates while the GEJ remains in place; type III, involving the herniation of both the GEJ and fundus; and type IV, in which other abdominal organs, such as the colon or spleen, are also involved. Clinical symptoms differ depending on the type and mechanism of the hernia. Sliding hernias typically induce reflux-related symptoms such as heartburn and regurgitation, whereas paraesophageal hernias may present with dysphagia, postprandial fullness, chest discomfort, or even respiratory symptoms due to mechanical compression. Diagnostic modalities include barium swallow radiography, endoscopy, computed tomography, and high-resolution manometry, each of which offers specific advantages in anatomical or functional assessments. Management depends on the symptom severity and hernia type. Sliding hernias without significant symptoms are often treated with proton-pump inhibitors and lifestyle modifications. Surgical repair, including Nissen or partial fundoplication, may be considered when symptoms become more severe or complications occur, particularly in paraesophageal hernias.