Approach

Diagnosis of hiatal hernia may be inferred through careful history and examination. It is important to stress that an unknown number of all patients with hiatal hernia (perhaps representing the majority) have minimal to no symptoms.

Signs and symptoms which might be elicited on a history and physical examination are mostly nonspecific and can only suggest the presence of a hiatal hernia. The diagnosis of hiatal hernia primarily is established through the use of diagnostic testing, including:[1]

  • Chest x-ray

  • Upper gastrointestinal fluoroscopy with oral contrast

  • Esophago-gastro-duodenoscopy

  • Computed tomography (CT) scan or magnetic resonance imaging (MRI).

Clinical history

Typical complaints from a patient with a symptomatic hiatal hernia might include: heartburn, reflux of sour liquid material (water brash), dull retrosternal chest pain (especially associated with swallowing), dysphagia, and crampy pain associated with swallowing (odynophagia).[6]​ Other symptoms may include vomiting undigested food, hematemesis, early satiety, bloating, hoarseness, and wheezing/dyspnea.

None of these symptoms are pathognomonic for hiatal hernia; they are nonspecific, and may be associated with other diseases. Some of these symptoms may be exacerbated by bending over, assuming a recumbent position, physical exertion, or any maneuver that increases intra-abdominal pressure. It is not possible to determine the type (I, II, III, or IV) of hiatal hernia using history and physical examination.

The patient presenting with a complicated hiatal hernia (involving obstruction, bleeding, and/or ischemia) may have the following symptoms:

  • severe chest pain

  • nonbilious vomiting

  • hematemesis (>50 cc)

  • dyspnea

  • fevers and chills

  • confusion

  • some, or all, of the complaints elicited with uncomplicated hiatal hernia.

Physical exam

Physical examination in a noncomplicated hiatal hernia also is nonspecific; findings which may suggest the presence of a hiatal hernia include:

  • Oropharyngitis (secondary to reflux of gastric contents)

  • Wheezing (secondary to aspiration of refluxate)

  • Decreased left chest breath sounds

  • Dullness to thoracic percussion

  • Presence of bowel sounds in the left chest.

Physical examination in a complicated hiatal hernia may reveal the following:

  • Pyrexia

  • Tachycardia

  • Hypotension

  • Tachypnea

  • Altered mental status

  • Some, or all, of the signs elicited with noncomplicated hiatal hernia.

Primary investigation

It is imperative that overuse of diagnostic modalities does not occur in these patients, as delay in treatment is associated with poor outcomes.[1]

A chest x-ray is a simple and inexpensive test and is indicated as the first test in all symptomatic patients.[1] Patients with hiatal hernia may have a retrocardiac air bubble in the intrathoracic portion of the stomach.

An upper gastrointestinal fluoroscopy with oral contrast is the key test for hiatal hernia, as it will delineate the anatomy and provide a qualitative assessment of esophageal motility.[17][18]​​ It is indicated as a primary test in patients with moderate or severe symptoms. Fluoroscopy may be performed with a barium esophagram, but an upper gastrointestinal series evaluation is recommended if the hernia is large for a complete assessment of the stomach.[17][Figure caption and citation for the preceding image starts]: Type IV paraesophageal hiatus hernia: (A) Frontal chest x-ray revealing a large intrathoracic gastric bubble (arrows); (B) Air-fluid level confirming intrathoracic gastric contents on the right lateral decubitus chest x-ray (arrow)BMJ Case Reports 2009 [doi:10.1136/bcr.06.2008.0302]; copyright@2009 by the BMJ Publishing Group [Citation ends].com.bmj.content.model.Caption@5c42a5c9

Subsequent tests

Endoscopy

Patients with moderate-to-severe reflux symptoms should undergo endoscopy to check for the presence of esophagitis and/or esophageal dysplasia; this information can help the clinician decide which therapy to pursue.[6]​ An esophago-gastro-duodenoscopy also can provide information on the anatomy of the hiatal hernia, although endoscopic anatomy sometimes can be misleading.

CT or MRI

CT scan or MRI is indicated when the diagnosis is not clear, other pathology is suspected, or when planning surgical intervention.[1] These investigations provide 3-dimensional reconstruction of the anatomy and thus determine whether organs other than the stomach have migrated into the chest.

Esophageal manometry and pH monitoring

Esophageal manometry and pH monitoring are indicated in patients with hiatal hernia and atypical symptoms, dysphagia, and/or when additional confirmation of the diagnosis is required.[19] A typical double hump pattern is seen on manometry. High resolution manometry (HRM) should be utilized as it can demonstrate various anatomic landmarks, such as the level of the diaphragmatic crura or the location of the lower esophageal sphincter. Calculating the size of a sliding component of a hiatal hernia is also possible with HRM.[1]

Abnormal pH monitoring results are seen with larger hiatal hernias. While this is not a necessary investigation for the diagnosis of hiatal hernia, it is useful when evaluating the need for antireflux surgery in addition to hernia repair.[1][20]

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