The Four Types of Hiatal Hernias

Instructor: Rachel Torrens
A hiatal hernia is a common medical occurrence, but did you know there are actually four types? In this lesson, follow a review of anatomical landmarks and discover the fine distinctions that differentiate one type from another.

Henry's Hernia

Henry, a 56-year-old male, comes into your office complaining of heartburn that ''comes and goes.'' Some days the burning sensation in his chest is very severe, other days he has no symptoms.

He notices that he is belching more and feel extremely full after meals. He reports that he was helping his son move out of his apartment three weeks ago and the symptoms started shortly thereafter. You examine him.

Henry's history of intermittent acid reflux and associated symptoms, his account of lifting heavy objects while helping his son move, and his examination all lead you to suspect a hiatal hernia. But which type of hiatal hernia?

Definition of a Hiatal Hernia

Before exploring the nuances of hiatal hernias, you must understand the anatomical landmarks of the upper digestive tract. Let's start at the top with the esophagus.

The esophagus is a soft tube connecting the throat to the stomach. The esophagus runs down the midline of the body and passes through a large, flat muscle known as the diaphragm. How is a soft tube supposed to penetrate a strong muscle? Well, it can't. But luckily, there's a hole or, as medical folk like to call it a hiatus, which means 'opening' in Latin. Specifically, it is referred to as the diaphragmatic esophageal hiatus.

The esophagus passes through a hiatus in the diaphragm to connect to the stomach.
upper digestive tract

Now, the esophagus extends down through the diaphragmatic esophageal hiatus to reach the stomach. The point of connection between the esophagus and the stomach is known as the gastroesophageal junction.

This sounds like a fancy term, but if you break it down you'll see it's quite logical. Anything with the prefix 'gastro-' refers to the stomach, 'esophageal' refers to the esophagus, and where the two meet is a junction! You'll often notice medical terminology that involves squishing two words together like this to pinpoint a location.

So, what is a hiatal hernia? A hiatal hernia is when a part or parts of the abdominal cavity squish upwards through the diaphragmatic esophageal hiatus into the chest cavity.

Four Types of Hiatal Hernias

Let's go over the four types of hiatal hernias.

Type I

Type I hernias account for 95% of all hiatal hernias. In Type I, the gastroesophageal junction slides upward through the diaphragmatic esophageal hiatus, hence the alternative name sliding hiatal hernia.

In Type I, the gastroesophageal junction slides upward through the diaphragmatic esophageal hiatus.
type 1 hernia

Despite their commonality, these hernias can be difficult to diagnose because the gastroesophageal junction can slide up out of normal position causing reflux-like symptoms in the patient, but then slide back down into its proper place, leaving the patient symptom-free. So the doctor needs to catch the hernia when the gastroesophageal junction is actually in the improper place.

Type II

Types II through IV are known collectively as paraesophageal hernias because each of these types involves a body part sliding up beside the esophagus.

A Type II hernia is also known as a pure paraesophageal hernia (PEH). In Type II hernias, the gastroesophageal junction remains in the correct place below the diaphragm, but part of the stomach rotates and bulges upward through the diaphragmatic esophageal hiatus. Pure PEHs are very rare, but can lead to serious complications.

In Type II hernias, part of the stomach rotates and bulges upward through the diaphragmatic esophageal hiatus.
type 2 hernia

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