Hiatal Hernia

• Two main types: sliding and paraesophageal

Sliding Hiatal Hernia (99%)

• EG junction lies above the diaphragm, or

• Distal most esophagus measures more than 50% of the diameter of the tubular esophagus=patulous cardia=predisposed to GE reflux, or

• Prominent gastric folds extend into distal esophagus from stomach

• May be reducible or incarcerated; sliding refers to EG junction, not to reducibility

Complications

• Large incarcerated hiatal hernias may slowly weep blood so that patients with them present with iron deficiency anemia, not reflux symptoms

• Peptic esophagitis from reflux

• Discrete marginal ulcers

• Strictures

Paraesophageal Hiatal Hernia

• Portion of stomach herniates through esophageal hiatus above diaphragm but EG junction continues to be subdiaphragmatic

• Usually non-reducible

• Not associated with GE reflux

Intrathoracic stomach

• Cardia may still be subdiaphragmatic

• Greater curvature may be on left or right side

Congenitally short esophagus (rare)

• Gastric ectopy by reason of lack of lengthening of esophagus

• Short, straight esophagus

• Frequently ulcer at EG junction

• GE reflux

• Antireflux mechanisms

• Large, incarcerated hiatal hernias

• Paraesophageal hiatal hernias

• “A” dynamic or contractile ring

• Cricopharyngeous muscle

WH/93