Definition- They are hernial defects in the diaphragm (a muscular structure that separates chest cavity and abdominal cavity) which leads to gradual enlargement of hiatal orifice  and subsequently abdominal contents tend to herniated into chest cavity. It is either naturally acquired condition means it develops spontaneously with age even without presence of any predisposing factors or it develops after some trauma to body leading to injury to diaphragm or GE Junction. 

All Hiatus hernia do not require surgical interventions.

Classification-

Type I- There is upward displacement of GE junction into chest cavity along with stomach. It can be symptomatic or completely asymptomatic also. May need surgical intervention to reduce it back to abdominal cavity.

Type II- In this type there is displacement of Stomach into the chest cavity along side the esophagus. GE Junction remains in it?s normal position. This happens due to the weakening of diaphragmatic tissue and phrenoesophageal membrane.

Type III- This is a combination of type I and type II of hernia in which both gastro-esophageal junction as well as fundus of stomach migrates into the chest cavity. This can be massive in size in that case it is known as ?GIANT ESOPHAGEAL HERNIA?.

Type IV- Known when hernial contents involve other abdominal structures like omentum, transverse colon and mesocolon or spleen.

Symptoms / Clinical presentations-

• Incidental detection during endoscopy or chest x-rays
• Early satiety, fullness after meals
• Regurgitation of food or fluids into mouth
• Acidity / chest pain
• Severe pain in chest and abdomen
• Repeated lung infections or pneumonia due to aspiration
• Iron deficiency anemia due to recurrent gastric bleeding

How to Diagnose Hiatus Hernia-

• Upright / standing chest x-ray film?Air fluid levels are seen
• Barium meal x-rays- Accurate information about type of hernia, extent of hernia, gastroesophageal reflux and gastric emptying information.
• CT scan of chest and abdomen- helps in preoperative evaluation of patient.
• Endoscopy Upper GI- Allows accurate evaluation, characterisation of hernia. Helps in taking biopsy from esophageal and gastric mucosa in rare case of Barret?s esophagus and malignant lesions in esophagus or stomach.
• 24 Hours PH testing and Manometry- Not absolutely indicated in symptomatic patients. Some physicians and surgeons perform it routinely on patients who are indicated for surgical intervention.

Treatement-

Who should undergo treatment?

• Any patient who is asymptomatic or has little symptoms at diagnosis but has large hernia defect.
• Patient who are symptomatic.

What are the options

• Medical / Non Surgical- Antacid therapy / Motility hurrying drugs or Prokinetic agents. Positioning in bed helps. Avoidance of irritating agents like-tea, coffee, chocolates, cigarette, small but frequent meals also help. 
• Surgical ? goal of therapy is bringing back normal anatomy inside the abdomen, ensuring that it remains inside the abdomen, re-inforcement of weekened diaphragm and crural tissue and prevent gastroesophageal reflux.

 CRURAL REPAIR & FUNDOPLICATION-

• Reduction of hiatal hernia contents along with sac is the primary step of surgery which is either done through chest (Transthoresic approach) or through abdomen (transabdominal-laparotomy) or through Laparoscopy. Laparoscopy has become more popular because of it?s added advantages like better visualization, easy access, minimum scaring and bleeding, rapid recovery and minimum discomfort to patient.
• Proper mobilization of esophagus to avoid shortening of it and failure of repair.
• After reduction of hernial contents, there is approximation of crural tissue with the help of unabsorbable suture material both in front and behind of esophagus to avoid angulation of GE Juntion. This repair can be inforced with use of some prosthetic material (PTFE Mesh or Bio absorbable collagen mesh) so that to give support to week diaphragmatic tissue.
• Fundoplication- Mobilization of greater curvature of stmach and wraping it around fundus  posteriorly and suturing it anteriorly and also with esophageal and crural tissue .