Snapshot A 55-year-old man presents to the emergency room for palpitations and shortness of breath. He never had this problem before but notes that this has been progressive since he started heavy weight lifting training. He also notes regurgitation and a feeling of food being stuck before passing. Introduction Overview a hernia through the esophageal hiatus of the diaphragm such that abdominal contents enter the chest treatment is usually lifestyle modifications and antacids, but surgery may be required Associated conditions gastroesophageal reflux Epidemiology Incidence under detected due to asymptomatic hernias Demographics majority are > 50 years of age Location esophageal hiatus within diaphragm Risk factors obesity older age trauma valsalva ETIOLOGY Pathogenesis mechanism sliding (type I, > 95%) gastroesophageal junction (GEJ) herniating through diaphragm paraesophageal (type II, III, and IV; < 10%) gastric fundus herniating through the diaphragm with the GEJ remaining below the diaphragm Presentation Symptoms majority are asymptomatic common symptoms location epigastric pain substernal regurgitation and dysphagia chest palpitations and shortness of breath duration intermittent Physical exam noncontributory to diagnosis inspection obesity Imaging Barium upper gastrointestinal radiograph series indications often after incidentally noted on plain chest radiograph clinical suspicion findings typically an outpouching of barium at the lower end of the esophagus sensitivity most sensitive diagnostic test for paraesophageal hernias poor sensitivity for small sliding hernias Studies Invasive studies endoscopy indications evaluate for suspected complications findings herniation through the diaphragm in retroflexed view erosive disease Barrett esophagus or neoplasm sensitivity and specificity poor sensitivity for small sliding hernias esophageal high-resolution manometry uncommonly used Differential Diffuse esophageal spasm key distinguishing factors uncoordinated esophageal contractions no hernia Achalasia key distinguishing factors high lower esophageal tone no hernia Gastroesophageal reflux disease key distinguishing factors no hernia Treatment Lifestyle elevate head of bed and avoid lying down after eating indications all patients weight loss indications overweight patients Medical antacids indications all patients modalities proton pump inhibitors histamine H2 receptor antagonists Surgical Nissen fundoplication (common) indications severe symptoms erosive complications large hernia risk of gastric strangulation Complications Gastric strangulation Barrett esophagus Aspiration pneumonia Malnutrition Gastrointestinal bleed Cameron lesion linear erosions where the stomach is constricted at the level of the hiatal hernia Prognosis Treatment relieves most symptoms