Giant Hiatal Hernia

General Considerations

• No uniform definition exists, but giant hiatal hernias are generally defined as a hernia containing greater than 30% of the stomach herniating into the thorax (others say more than 50%)
• They account for 0.3 to 15% of all hiatal hernias
• It is believed that the size of the hiatal hernia increases as patients age, probably due to an increase in intra-abdominal pressure
• It is likely that in most giant hiatal hernias, both the esophago-gastric junction and the fundus of the stomach lie above the diaphragm (mixed paraesophageal hernia –type III)
• This type may also volvulate and produce symptoms of acute esophageal obstruction

Clinical Findings

• Heartburn
• Chest pain
• Dysphagia
• Shortness of breath
• Chronic blood loss leading to anemia

Imaging Findings

• Large air or contrast filled structure just posterior to the heart
• Because of its size, the density is frequently mid-line in the frontal projection

Differential Diagnosis

• Bochdalek hernias are more posterior and do not involve the esophagus

Treatment

• Large hiatal hernias are less amenable to conservative therapy to prevent heartburn
• Recurrence rates vary with technique

 
Large Hiatal hernia. On the frontal radiograph, there is a large, air-containing structure superimposed on the heart (white arrows). The lateral view demonstrates a retrocardiac air-filled lumen (yellow arrows) with an air-fluid level (red arrow).

Wo JM, Branum GD, Hunter JG, Trus TN, Mauren SJ, Waring JP. Clinical features of type III (mixed) paraesophageal hernia. Am J Gastroenterol. 1996;91:914–916.

Mitiek, M.O. and Andrade, R.S. Giant hiatal hernia. Ann Thorac Surg. 2010; 89: S2168–S2173