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Sliding and Paraesophageal Hiatal Hernias Types 1, 2, and 3
Hiatal hernias develop in 10% to 50% of the population with an average age of 48 for patients with a sliding hernia and 65 to 75 for a paraesophageal hernia. There are four types of hiatal hernias. Type 1, accounting for over 90% of all hernias, develops when the gastroesophageal junction (GEJ) slides above the diaphragm. The remaining hernias, 10%, are either type 3 or mixed type 2, which is a pure paraesophageal hernia. Type 2 hernias develop when the gastric fundus herniates into the chest, lateral to the esophagus, but the GE junction remains fixed in the abdomen; these account for 14% of the remaining 14% of hernias. Type 3, or mixed paraesophageal hernias, account for 86% of the remaining 14% of hernias. They develop with movement of the lower esophageal sphincter (LES) and the fundus into the chest ( Figs. 12.1 and 12.2 ). The type 4 hernia is a subset of type 3 and contains not only the entire stomach but also other viscera, such as the omentum, colon (13%), spleen (6%), and small bowel. Parahiatal hernia is movement of the stomach through a diaphragmatic defect separate from the hiatus and accounts for less than 1% of all hiatal hernias.
Type I: Sliding Hiatal Hernia.
Paraesophageal Hernias. (A) Type II. (B) Type III.
A hiatal hernia forms as the phrenoesophageal membrane, preaortic fascia, and median arcuate ligament become attenuated over time. The pressure differential between the abdomen and the chest creates a vacuum effect during inspiration that pulls on the stomach. The degree of herniation into the posterior mediastinum and the type of volvulus that occurs may depend on the relative laxity of the gastrosplenic, gastrocolic, and gastrohepatic ligaments. As the hiatal hernia becomes larger, two types of volvulus may develop. Organoaxial volvulus (longitudinal axis) occurs with movement of the greater curvature of the stomach anterior to the lesser curvature. Mesenteric axial volvulus is less common and occurs when the stomach rotates along its transverse axis.
When the GEJ cannot be reduced below the diaphragm, despite extensive dissection in the mediastinum, then a shortened esophagus is present. This phenomenon is believed to occur in patients with chronic gastroesophageal reflux disease (GERD), with resultant transmural inflammation and contraction of the esophageal tube.
Clinical Picture
Although small type 1 hiatal hernias may be asymptomatic, most patients complain of typical and atypical symptoms of GERD. Heartburn is the main symptom of GERD, but patients may also complain of acid reflux, regurgitation of food, epigastric abdominal pain, dysphagia, odynophagia, nausea, bloating, and belching. Atypical or extraesophageal symptoms include noncardiac chest pain, choking, laryngitis, coughing, wheezing, difficulty breathing, sore throat, hoarseness, asthma, and dental erosions.
Symptoms of type 2 and 3 paraesophageal hernias differ from GERD symptoms. Although the symptoms vary, most series describe dysphagia, chest pain, and regurgitation as the most common. One series defined the symptoms as regurgitation (77%), heartburn (60%), dysphagia (60%), chest pain (52%), pulmonary problems (44%), nausea, and vomiting (35%), hematemesis or hematochezia (17%), and early satiety (8%). Asymptomatic patients may constitute 11% of the population, and the hernia may be discovered on routine chest radiography or endoscopy. Questioning may reveal the presence of symptoms in most patients.
Dysphagia may result from twisting of the esophagus by a herniated stomach. Chest pain may be confused with angina, resulting in emergency cardiac evaluation with negative results. Dyspnea may be secondary to loss of intrathoracic volume. Coughing may be a sign of aspiration, which can develop into pneumonia or bronchitis.
Iron-deficiency anemia occurs in 38% of patients. Usually but rarely is there evidence of gastrointestinal (GI) bleeding. Cameron ulcers or mucosal ulcerations of the stomach, found in 5.2%, are a cause of anemia. Ischemia and mucosal injury occur secondary to the friction of the stomach moving through the esophageal hiatus during respiration.
Postprandial distress —defined as chest pain, shortness of breath, nausea, and vomiting—occurs in 66% of patients. Eventually, as the hernia enlarges, most patients have these symptoms. Conversely, as a hernia enlarges, heartburn decreases. Heartburn is less common in type 3 than in type 1 hernias.
As many as 30% of patients will need emergency surgery for bleeding, acute strangulation, gastric volvulus, or total obstruction. Surgery is performed to treat perforation after strangulation with peritonitis, but mortality is 17%. If gastric necrosis has developed, mortality may reach 50%.
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