3. Hiatus Hernia

📄 Definition

A hiatus hernia occurs when part of the stomach herniates through the diaphragm into the thoracic cavity via the oesophageal hiatus. It is commonly associated with gastro-oesophageal reflux disease (GORD).

Types of Hiatus Hernia (Mnemonic: SPPM)

  1. Sliding (Type I) – most common (≈ 90%)

    • Gastro-oesophageal junction and part of stomach slide into chest

  2. Para-oesophageal (Type II) – GE junction remains in abdomen; part of stomach herniates beside the oesophagus

  3. Mixed (Type III) – both GE junction and stomach herniate

  4. Massive (Type IV) – herniation of other abdominal organs (e.g. colon, small bowel)

🛡️ Risk Factors (Mnemonic: AWEIGH)

  • Ageing (weakened diaphragm, especially >50)

  • Weight gain (increased intra-abdominal pressure)

  • Elevated intra-abdominal pressure (e.g. pregnancy, chronic cough)

  • Iatrogenic (post-surgical)

  • GORD

  • Heavy lifting or straining

Clinical Features (Mnemonic: CHEST)

  • Chest discomfort or epigastric pain

  • Heartburn and acid reflux (common in sliding hernia)

  • Early satiety

  • Swallowing difficulty (dysphagia) in large or para-oesophageal hernias

  • Throat symptoms: hoarseness, cough, regurgitation

Many cases are asymptomatic and found incidentally on imaging.

⚠️ Alarm Features

Prompt referral for urgent OGD or surgical review if:

  • GI bleeding (melaena or haematemesis)

  • Persistent vomiting

  • Severe or worsening dysphagia

  • Evidence of obstruction or strangulation

  • Iron-deficiency anaemia

🔬 Investigations

  • OGD (gastroscopy) – confirms diagnosis and excludes malignancy or complications

  • Barium swallow – useful for anatomical detail (e.g. type of hernia)

  • CT chest/abdomen – in uncertain or severe cases

  • 24-hour pH monitoring / manometry – if diagnosis uncertain or pre-surgical planning

📋 Management (Mnemonic: LAPS)

Lifestyle modification

  • Weight loss

  • Avoid large meals and lying flat after eating

  • Raise head of bed

  • Avoid caffeine, alcohol, chocolate, spicy food

Acid suppression therapy

  • PPI (e.g. omeprazole 20 mg OD) is first-line

  • H2-receptor antagonists if PPI not tolerated

Procedural / Surgical intervention

  • Indications: severe symptoms, para-oesophageal hernia, volvulus, failed medical therapy

  • Surgery: laparoscopic hernia repair with fundoplication

Surveillance (if asymptomatic)

  • Monitor for symptom progression or complications

⚠️Complications (Mnemonic: BAGS)

  • Bleeding (from erosive oesophagitis)

  • Anaemia (chronic blood loss)

  • Gastric volvulus (especially in para-oesophageal hernia)

  • Strangulation → surgical emergency

Last updated in line with NICE CKS: Dyspepsia – reflux
Published: May 2010 • Last updated: April 2023
Last reviewed: July 2025
PASSMAP ensures all content is NICE-aligned and reviewed for Physician Associate Registration Assessment (PARA) success

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