Definition of the disease
Hiatal hernia :
A hiatal hernia is a condition in which elements of the abdominal cavity pass through the esophageal hiatus of the diaphragm. There are two main types of hiatal hernias:
- Sliding hernia (Type I) : The gastroesophageal junction (GEJ) moves above the diaphragm, while the stomach remains in its usual alignment.
- Paraesophageal hernia (Types II, III, IV) : The gastric fundus moves upwards, sometimes with other abdominal organs, into the thorax. About 95% of hiatal hernias are sliding hernias, and 5% are paraesophageal hernias.
Symptoms
Clinical features :
- Sliding hernia : Often asymptomatic, but large hernias can lead to symptoms of gastroesophageal reflux disease (GERD).
- Paraesophageal hernia : May also be asymptomatic or cause vague symptoms such as epigastric or substernal pain, a feeling of fullness after meals, nausea, and retching. In some cases, an upright X-ray or a CT scan may reveal an air-fluid level in the thorax.
Causes
Etiology :
- Sliding hernia : Often due to a progressive disruption of the gastroesophageal junction, allowing part of the stomach to move up into the thorax.
- Paraesophageal hernia : Associated with abnormal laxity of the gastrosplenic and gastrocolic ligaments, allowing the stomach to move into the thoracic cavity.
Specific causes include trauma, congenital malformations, or iatrogenic factors (e.g., after hiatus surgery).
Treatment
Management :
- Sliding hernia : Surgical repair is generally not necessary for asymptomatic hernias. Treatment of symptoms, mainly gastroesophageal reflux disease (GERD), is the primary intervention.
- Paraesophageal hernia : Surgical repair is recommended for symptomatic patients or in the presence of serious complications such as gastric volvulus, bleeding, obstruction, strangulation, perforation, or respiratory failure.
Use of medical imaging
Imaging diagnosis :
- Upper gastrointestinal endoscopy : Often used to discover a hiatal hernia during an evaluation for gastroesophageal reflux or for other reasons.
- Barium swallow : The most sensitive diagnostic test for paraesophageal hernias. It can also detect sliding hernias larger than 2 cm in axial diameter.
- CT scan or MRI : Used to visualize complex paraesophageal hernias or to assess associated complications.
Medical imaging plays a crucial role in the detection and classification of hiatal hernias, as well as in planning appropriate treatment based on the size and symptoms associated with the hernia.
Source: UpToDate