A hiatus hernia occurs when part of the stomach protrudes through the diaphragm up into the thoracic cavity.

There are two types; sliding hiatus hernia and rolling hiatus hernia. Sliding hiatus hernias account for up to 95% of all hiatus hernias.
They can be congenital or may develop over the course of time.
They are clinically significant as they are associated with an increased incidence of Gastro-oesophageal reflux disease (GORD)

Sliding hiatus hernia

Part of stomach at the oesophageal gastric junction is pulled upwards through the diaphragm. This reduces the angle between the oesophagus and the stomach, and thus removes one of the natural anatomical barriers to reflux. However, it is unlikely that this is the sole cause for reflux, as many people have a hiatus hernia and suffer no reflux symptoms. The hernia itself never causes any symptoms – it may however contribute to reflux which will produce symptoms.

  • This type of hernia is only covered by peritoneum on its lateral and anterior sides. The posterior is not covered due to the ‘bare area’ on the back of the stomach.

Rolling hiatus hernia

(aka para-oesophageal hernia)

This occurs when part of the fundus of the stomach will extend through the diaphragm at a separate site to the oesophagus. They can sometimes be huge, with almost the whole stomach becoming herniated, leaving the gastro-oesophageal junction lying right alongside the pylorus.

  • This type of hernia is completely surrounded by a peritoneal sac.
  • Symptoms develop very rarely, and often the hernia is discovered by accident on a CXR, indicated by a fluid level behind the mediastinum. When it does cause problems, then it may cause pain (due to stomach twisting), pain and discomfort after eating, and vomiting. It may present acutely if the hernia is strangulated.
It is possible in some patients for both types of hiatus hernia to exist simultaneously. This is in fact more common than a rolling hernia on its own, and is known as a mixed hiatus hernia. In this condition, reflux is relatively common.

 Illustrations of sliding hiatus hernia and rolling hiatus hernia

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