Comparative assessment of clinical and endoscopic semiotics of hiatal hernias




hiatal hernia, diagnostic, semiotics, subtype hernia


A hiatal hernia (HH) of type III combines the anatomical characteristics of HH types I and II. The manifestations of type III HHs are diverse, and they can originate from either type I or type II, but so far, there is no certainty regarding the correlation between the clinical and endoscopic manifestations of HH type III and its origin.

Objective —  Based on the analysis of clinical and endoscopic manifestations of type III HH, justify the diversity of their characteristics depending on whether they originate from type I or type II HH.

Materials and methods. The study included 126 patients with HH, including 87 type III hernias and 39 type I hernias, who underwent elective laparoscopic hernioplasty. The study consisted of several steps. In the first step, an assessment of the results of endoscopic examination in patients with type III HH was conducted to determine the diversity of the obtained data and the feasibility of dividing patients into subgroups using a two‑stage cluster analysis. In the second step, the subgroups obtained through cluster analysis were compared between themselves and with the patients with type I HH to determine the similarities or differences in endoscopic findings and clinical symptoms.

Results. Cluster analysis identified two clusters of indicators with a strong degree of association and differentiation. The main factor in the differentiation into clusters was the relationship between the gastroesophageal junction (GEJ) and the upper border of the HS (hernia sac) in an inversion. Based on this criterion, type III HH can be divided into two subgroups: type IIIA, where the GEJ is located proximally or at the same level as the highest point of the HS, and type IIIB, where the GEJ is located distally to the highest point of the HS. The occurrence of most endoscopic symptoms of HH in subgroup IIIA, in contrast to IIIB, did not significantly differ from type I HH, except for the shorter length of the esophagus and the greater axial length of the hernia. Additionally, patients with the IIIA HH subtype were almost indistinguishable from those with type I HH in terms of clinical characteristics, except for a higher average age and the occurrence of dyspnea. In subtype IIIB, compared to type I, symptoms related to gastroesophageal reflux were significantly less frequent, while symptoms indicative of impaired food evacuation were more frequent. The observed similarity between the endoscopic and clinical manifestations of type I and subtype IIIA HH suggests a common origin for these conditions. On the other hand, subtype IIIB, which differs in endoscopic and clinical indicators from type I and subtype IIIA HH, is evidently the result of the progression of type II HH.

Conclusions. Patients with type III HH exhibit significant diversity in clinical and endoscopic manifestations, which is attributed to the different origins of the HH (from type I or type II). An endoscopic feature indicating the hernia’s origin is the position of the GEJ relative to the highest point of the HS: below it corresponds to type II HH (62.1%), while at or above it corresponds to type I HH (37.9%).


Author Biographies

T. A. Tarasov, Bogomolets National Medical University, Kyiv

Head of Department of Diseases of a Surgical Profile University Clinic

L. Y. Markulan, Bogomolets National Medical University, Kyiv

PhD (Med), Associate Professor


Barrett NR. Hiatus hernia: a review of some controversial points. Br J Surg. 1954 Nov;42(173):231-43. PMID: 13219304.

Bild DE, Bluemke DA, Burke GL, Detrano R, Diez Roux AV, Folsom AR, Greenland P, Jacob DR Jr, Kronmal R, Liu K, Nelson JC, O’Leary D, Saad MF, Shea S, Szklo M, Tracy RP. Multi-Ethnic Study of Atherosclerosis: objectives and design. Am J Epidemiol. 2002 Nov 1;156(9):871-81. PMID: 12397006.

Dreifuss NH, Schlottmann F, Molena D. Management of paraeso­phageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies. Dis Esophagus. 2020 Aug 3;33(8):doaa045.

Edmundowicz SA, Clouse RE. Shortening of the esophagus in response to swallowing. Am J Physiol. 1991 Mar;260(3 Pt 1):G512-6. PMID: 2003613.

Gerdes S, Schoppmann SF, Bonavina L, Boyle N, Müller-Stich BP, Gutschow CA; Hiatus Hernia Delphi Collaborative Group. Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus. Surg Endosc. 2023 Jun;37(6):4555-4565.

Hashemi M, Sillin LF, Peters JH. Current concepts in the management of paraesophageal hiatal hernia. J Clin Gastroenterol. 1999 Jul;29(1):8-13. PMID: 10405224.

Hutter MM, Rattner DW Paraesophageal and other complex diaphragmatic hernias. In: Yeo CJ (ed) Shackelford’s surgery of the alimentary tract. Saunders Elsevier, Philadelphia, 2007, pp 549-562.

Jung JJ, Naimark DM, Behman R, Grantcharov TP. Approach to asymptomatic paraesophageal hernia: watchful waiting or elective laparoscopic hernia repair? Surg Endosc. 2018 Feb;32(2):864-871. Epub 2017 Aug 4. PMID: 28779249.

Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol 2008;22:601-16. 10.1016/j.bpg.2007.12.007.

Kavic SM, Segan RD, George IM, Turner PL, Roth JS, Park A. Classification of hiatal hernias using dynamic three-dimensional reconstruction. Surg Innov. 2006 Mar;13(1):49-52. PMID: 16708155.

Kim P, Turcotte J, Park A. Hiatal hernia classification-Way past its shelf life. Surgery. 2021 Aug;170(2):642-643. Epub 2021 Apr 15.PMID: 33867168.

Kohn GP, Prince RR, DeMeester SR, et al. Guidelines for the management of hiatal hernia, Surg. Endosc. 27 2013 4409-4428,

Landreneau RJ, Del Pino M, Santos R. Management of paraesophageal hernias. Surg Clin North Am. 2005 Jun;85(3):411-32. PMID: 15927641.

Li L, Gao H, Zhang C, Tu J, Geng X, Wang J, Zhou X, Pan W, Jing J.. The diagnostic value of X-ray, endoscopy, and high-resolution manometry for hiatal hernia: a systematic review and meta-analysis. Journal of Gastroenterology and Hepatology. 2019, 2020 Jan;35(1):13-18. Epub 2019 Jul 28.

Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, Johnson F, Hongo M, Richter JE, Spechler SJ, Tytgat GN, Wallin L. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999 Aug;45(2):172-80. PMID: 10403727; PMCID: PMC1727604.

Nayar DS, Vaezi MF. Classifications of esophagitis: who needs them? Gastrointest Endosc. 2004 Aug;60(2):253-7. PMID: 15278054.

Nykonenko A. O., Haidarzhi Ye. I., Letkeman T. V. Hiatal hernia types and their radiological diagnostics in patients with gastroesophageal reflux disease Zaporizhzhya Medical Journal. 2022:24(2, 131);168-175.

Paul S, Bueno R. Hiatal Hernia. Encyclopedia of Gastroenterology. 2004; 382-386.

Petrov RV, Su S, Bakhos CT, Abbas AE. Surgical Anatomy of Paraesophageal Hernias. Thorac Surg Clin. 2019 Nov;29(4):359-368.

Schieman C, Grondin SC. Paraesophageal hernia: clinical presentation, evaluation, and management controversies. Thorac Surg Clin. 2009 Nov;19(4):473-84. PMID: 20112630.

Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J Thorac Cardiovasc Surg. 1967 Jan;53(1):33-54. PMID: 5333620.

Weston AP. Hiatal hernia with cameron ulcers and erosions. Gastrointest Endosc Clin N Am. 1996 Oct;6(4):671-9. PMID: 8899401.




How to Cite

Tarasov T, Markulan L. Comparative assessment of clinical and endoscopic semiotics of hiatal hernias. ЗХ [Internet]. 2023Nov.17 [cited 2024Jul.21];(2):25-3. Available from:



Original Research