Atypical and typical manifestations of the hiatal hernia

Abstract

: Hiatal hernias may present in variety of ways, both typical and atypical. Manifestations are dependent on the type and size of the hernia. Gastrointestinal manifestations are the most common, predominately with GERD and associated syndromes. Typical GERD presents with heartburn and regurgitation as part of a reflux syndrome. Additionally, GERD may manifest as a typical chest pain syndrome unrelated to a cardiac etiology. Hiatal hernia associated GERD may present with esophageal mucosal injury in the form of reflux esophagitis, stricture, Barrett’s esophagus, and progress to esophageal malignancy. Atypical GERD symptoms like cough, laryngitis, asthma, and dental erosions may be may exist with hiatal hernias. GERD symptoms are more often associated with type 1 hiatal hernias. Typical gastrointestinal obstructive symptoms of hiatal hernia manifest as nausea, bloating, emesis, dysphagia, early satiety, and postprandial fullness and pain in the epigastrium and chest. Less common, atypical presentations include gastric outlet obstruction, secondary gastric volvulus, intestinal obstruction and ischemia, and bleeding. These manifestations occur more frequently with paraesophageal hernias. Bleeding, ulcerations in the form of Cameron lesions, and iron deficiency anemia are additional atypical manifestations of hiatal hernia. As hiatal hernias enlarge and move more into the thorax, non-gastrointestinal symptoms become more frequent. Typical pulmonary presentations consist of dyspnea, dyspnea on exertion, and atelectasis as a result of pulmonary compression. Similarly, compression on the left atrium may explain the higher prevalence of atrial fibrillation in patients with hiatal hernia. Pulmonary fibrosis remains an atypical presentation of hiatal hernia, likely associated with the increased prevalence of GERD in hiatal hernia.