Pathophysiology & Risk Factors

Part of the stomach protrudes upward through the esophageal hiatus of the diaphragm into the thoracic cavity. Two types exist: a sliding (Type I) hernia (~95%) — the GE junction and fundus slide upward, mimicking GERD; and a paraesophageal (rolling, Type II) hernia (~5%) — the fundus rolls up beside the esophagus while the GE junction stays in place, creating risk of incarceration and strangulation. Risk factors raise intra-abdominal pressure.

Sliding vs Paraesophageal

Sliding (Type I)Paraesophageal (Type II)

Frequency~95%~5%

GE junctionSlides upwardStays in place

AnatomyJunction + fundus riseFundus rolls up beside esophagus

SymptomsGERD / heartburnDysphagia, can't vomit, severe pain

RiskReflux (annoying)Strangulation (dangerous)

ManagementConservativeSurgical repair

Sliding (Type I)

Frequency: ~95%
GE junction: Slides upward
Anatomy: Junction + fundus rise
Symptoms: GERD / heartburn
Risk: Reflux (annoying)
Management: Conservative

Paraesophageal (Type II)

Frequency: ~5%
GE junction: Stays in place
Anatomy: Fundus rolls up beside esophagus
Symptoms: Dysphagia, can't vomit, severe pain
Risk: Strangulation (dangerous)
Management: Surgical repair

Signs & Symptoms

EarlyProgresses →

heartburn

sliding type; worsens after meals and when supine

substernal burning pain

postprandial; sliding type reflux

regurgitation

Late / Severe

dysphagia

acute onset suggests paraesophageal obstruction

sudden severe chest pain

paraesophageal; mimics cardiac pain

inability to vomit Hallmark

retching without vomitus — one component of Borchardt's triad (with epigastric distension + inability to pass an NG tube); signals gastric volvulus

Diagnostics & Labs

barium swallow

confirms hernia and differentiates type

upper endoscopy

ECG

obtained first to rule out cardiac cause of chest pain

Interventions & Priorities

elevate HOB at least 30 degrees

small frequent meals

reduces gastric distension and intra-abdominal pressure

stay upright after eating

avoid lying down 2-3 hours after meals

incentive spirometry

post-fundoplication; prevents atelectasis from upper-abdominal surgery

Treatments & Medications

acid-reducing therapy

antacids / acid suppression for sliding-type reflux

Nissen fundoplication

surgical repair; wraps fundus around lower esophagus to reinforce sphincter

Patient Teaching

weight loss

avoid large meals

avoid tight waistbands

avoid bending after meals

avoid lying down 2-3 hours after eating

small-volume clear liquids after fundoplication

prevents gastric overdistension protecting the wrap

Complications

incarceration

paraesophageal type

strangulation Hallmark

vascular compromise; surgical emergency

gastric ischemia

gastric necrosis

perforation

Report Nowescalate immediately

sudden severe epigastric pain

paraesophageal incarceration/strangulation

sudden severe chest pain

rule out cardiac with ECG, but think rolling hernia emergency

acute dysphagia

inability to vomit despite retching Hallmark

component of Borchardt's triad (epigastric distension, retching without vomiting, cannot pass NG tube) — gastric volvulus emergency

hemodynamic instability

tachycardia + hypotension signal strangulation

Clinical Pearl

Sliding slides and refluxes — annoying. Rolling rolls and strangulates — dangerous. Sudden severe pain plus can't-vomit equals a rolling-hernia surgical emergency.

Hiatal Hernia