Snap Shot A 45-year-old man presents to the emergency room with chest pain, difficulty swallowing, and heartburn after meals, especially when reclining. Introduction Herniation of the stomach through the diaphragm into the chest cavity Type I sliding hiatal hernia most common type (>95%) occurs at the GE junction stomach slides into the mediastinum Type II paraesophageal hiatal hernia (<5%) herniation of stomach fundus through diaphragm GE junction remains below diaphragm parallel to the esophagus Associated with GERD in 80% of sliding hiatal hernia cases Presentation Symptoms may be asymptomatic, usually identified incidentally on radiography chest pain heart burn GERD Physical exam usually no significant findings Evaluation Barium swallow may observe stomach in chest cavity Usually an incidental finding Differential Diffuse esophageal spasm, achalasia, nutcracker esophagus, GERD Treatment Medical management symptom management and lifestyle modifications indicated in type I (sliding hiatal hernias) to relieve GERD symptoms antacids weight loss dieting Surgical intervention surgical repair indicated in type II (paraesophageal cases) due to risk of strangulation Prognosis, Prevention, and Complications Prognosis treatment relieves most symptoms Prevention lifestyle modifications can prevent symptoms Complications aspirate pneumonia gastric strangulation iron-deficiency/malnutrition