History and exam

Key diagnostic factors

common

presence of risk factors

A key risk factor is obesity. Other risk factors include previous gastro-oesophageal procedure and elevated intra-abdominal pressure.

uncommon

bowel sounds in chest

If present, suggestive of hiatus hernia.

Other diagnostic factors

common

heartburn

Patients with sliding type I hiatus hernias always have associated gastro-oesophageal reflux disease (GORD).[4]​[21]​​​​​ Type II and III (para-oesophageal) hiatus hernias may or may not have associated GORD. A burning sensation in the chest after meals is typical.

regurgitation

Acid, liquids, and food may passively come back up into the mouth, particularly when patients lie flat.[6][12] Patients may describe this as a sour or metallic taste in the mouth.

obesity

Obesity is associated with an increased incidence of hiatal hernia.[11]

uncommon

chest pain

Oesophageal spasm as a result of reflux of acid can result in central chest discomfort that can be mistaken for cardiac pain.[6][12]

Severe chest pain may be a presenting feature of a complicated hiatus hernia (involving obstruction, bleeding, and/or ischaemia).

dysphagia

Difficulty swallowing may occur in patients with oesophagitis due to acid reflux.[6][12]

odynophagia

Painful swallowing may occur in patients with oesophagitis due to acid reflux.

haematemesis

Oesophageal irritation due to acid reflux may manifest as blood in vomitus.

Haematemesis of >50 cc may be a presenting feature of a complicated hiatus hernia (involving obstruction, bleeding, and/or ischaemia).

shortness of breath

May be the result of compromised lung expansion because of the space occupied by the hiatus hernia.

Dyspnoea may be a presenting feature of a complicated hiatus hernia (involving obstruction, bleeding, and/or ischaemia).

cough

May be the symptom of chronic or acute aspiration.

oropharyngitis

The throat appears inflamed.

wheezing

A result of bronchospasm, which is secondary to aspiration.

non-bilious vomiting

Non-bilious vomiting may be a presenting feature of a complicated hiatus hernia (involving obstruction, bleeding, and/or ischaemia).

fever and chills

Fever and chills may be a presenting feature of a complicated hiatus hernia (involving obstruction, bleeding, and/or ischaemia).

confusion

Confusion may be a presenting feature of a complicated hiatus hernia (involving obstruction, bleeding, and/or ischaemia).

Risk factors

strong

obesity

Obesity is associated with an increasing incidence of hiatus hernia.​​[11]​​ The explanation may be that abdominal obesity increases intra-abdominal pressure, which pushes the stomach against the oesophageal hiatus.[11]​

increased age

The prevalence of hiatus hernia increases with age.[11][12]

weak

previous gastro-oesophageal procedure

Iatrogenic hiatus hernia typically occurs in patients who have had a previous anti-reflux procedure or hiatus hernia repair, but patients who have undergone oesophagectomy are also at increased risk.[8] Postoperative herniation of the stomach into the chest occurs in about 1% to 2% of patients undergoing a primary anti-reflux procedure.[13]

elevated intra-abdominal pressure

In general, a condition that produces chronic elevations in intra-abdominal pressure predisposes a person to hiatus hernia.[8]​​ This includes chronic cough, pulmonary disease, strenuous exercise, ascites, and multiparity.

male sex

One meta-analysis of 18 studies found that hiatus hernia was more common in men (OR 1.36, 95% CI 1.10 to 1.68).[11]

incisional, umbilical, or inguinal hernia

Patients may have a history, or presence, of incisional, umbilical, or inguinal herniation.[14][15][16]

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