How to Check for a Hiatal Hernia

Diagnosing a hiatal hernia involves imaging studies like X-rays, CT scans, and endoscopy. Although severe hiatal hernias might be evident for self-diagnosis, most are much too small to be felt and a healthcare provider will need to run tests.

A hiatal hernia occurs when a portion of the stomach, and sometimes other abdominal structures, is able to bulge upward into the chest through a defect in the diaphragm. Since most hiatal hernias do not cause symptoms, they are usually discovered during a routine chest X-ray for an unrelated condition. At other times, a hiatal hernia may be suspected in people with severe acid reflux who fail to respond to antacids or other treatments. For such cases, there are several tests healthcare providers can use to confirm the diagnosis.

In this article, the various methods of testing for hiatal hernias are discussed, along with how hiatal hernias are classified. It will also discuss the differential diagnosis of hiatal hernias.

X-Rays

Since a hiatal hernia often doesn’t cause serious symptoms, the first clue that you have a hernia may come when your healthcare provider reviews a chest X-ray ordered for an unrelated issue. Your healthcare provider will likely order additional tests to be sure the image that appears isn’t a lung abscess or other possible disorder.

Smaller hiatal hernias are often challenging to spot on a regular X-ray and may only appear as a gas-filled structure in the chest cavity. Imaging tests such as an upper GI barium study or computed tomography (CT) scan may also be ordered to provide better definition.

Barium Swallow

The preferred method of diagnosis of a hiatal hernia is an upper gastrointestinal (GI) barium study. Known as a barium swallow or an esophagram, the test requires you to drink roughly 1.5 cups of chalky fluid containing barium sulfate and, about 30 minutes later, undergo a series of X-rays. The metallic substance coats the esophagus and stomach, helping to isolate them in the imaging results. 

Expect to be strapped to a table as you undergo the X-rays. During the study, the table is tilted as you drink additional barium. 

CT Scan

A barium study is often enough to make a definitive diagnosis. When it's unable to do so, a computed tomography (CT) scan may be ordered. This may be necessary for people who are obese or have undergone previous abdominal surgery.

Upper GI Endoscopy

A hiatal hernia can also be diagnosed with a procedure known as an upper GI endoscopy. This is a direct viewing method in which a flexible scope, called an endoscope, is inserted into your throat to get live images of the esophagus, stomach, and duodenum (the first part of the small intestines).

The procedure will require you to stop eating or drinking four to eight hours before testing. Before the procedure, you are given an intravenous sedative to help relax you. A numbing spray for your throat may also be used. The procedure usually takes between 10 and 20 minutes, with an additional hour needed to recover from the sedation.

Esophageal Manometry

Esophageal manometry is a newer technology that evaluates how the muscles of the esophagus and esophageal sphincter (valve) are functioning, whereas a possible diagnostic test is more commonly done after diagnosis and before a possible surgical repair. Esophageal manometry can help your healthcare provider identify motor dysfunctions, such as dysphagia (difficulty swallowing), and how your hernia may contribute to them.

The procedure is performed by first anesthetizing a nostril with a numbing ointment. A thin tube with sensors is fed through your nostril and down to your esophagus. The digital monitor allows the technician to view and record changes in relative pressure as you swallow.

Esophageal pH Monitoring

Esophageal pH monitoring is a test used to record changes in the acidity of your esophagus over a period of time (as measured by the pH). It also involves the insertion of a tube-like sensor through the nostril, which is connected to a monitor you wear on your belt. During the next 24 hours, the monitor registers every time you experience acid reflux and records the varying changes in pH levels. While a possible test for diagnosing hiatal hernia, it is not commonly used.

Self Diagnosis

You’ll need a medical test to tell if you have a hiatal hernia. In some instances, a hernia may be large enough for you to feel through your skin, which would result in an enlarged opening around your diaphragm. However, hiatal hernias are usually too small to be felt with your own hands.

Classifying a Hiatal Hernia

Once a hiatal hernia is diagnosed, it is classified by type, which can help direct treatment and/or be used to monitor any changes in your condition. The types are classified by the size and characteristics of the hernia:

• Type 1 is known as a sliding hernia; the stomach remains in its usual alignment while the herniated portion slips in and out of the hiatus (the hole in the diaphragm through which the esophagus passes). Most hiatal hernias are type 1.
• Type 2 is a paraesophageal hernia, which doesn't slide in and out of the hiatus but remains relatively fixed next to the esophagus.
• Type 3 occurs when the gastroesophageal junction (the junction between the esophagus and stomach) begins to bulge through the hiatus.
• Type 4 occurs when the herniation allows the stomach and other organs, such as the colon or liver, to infiltrate the chest cavity.

Hiatal Hernia Doctor Discussion Guide

Get our printable guide for your next appointment to help you ask a healthcare provider the right questions.

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Differential Diagnosis

Acid reflux symptoms are not uncommon in people with a hiatal hernia. Large hernias may cause other, more profound symptoms such as severe chest pain, vomiting, retching, and aspiration pneumonia (caused by coughing up food into the lungs).

Some of the other possible causes include:

• Angina, which can be differentiated during a cardiac stress test
• Pneumonia, the causes of which may be differentiated by a chest X-ray and blood tests
• Gastroesophageal reflux disease (GERD), which can be differentiated by the chronic nature of the symptoms, as well as signs of esophageal or tooth erosion
• Gastric outlet obstruction, which can be differentiated by impairment at the pylorus (the opening from the stomach into the duodenum) rather than the hiatus

Summary

While you might want to check yourself for hiatal hernia, imagine tests are almost always needed to make a diagnosis. Such studies might include X-rays, barium swallow tests, CT scans, or endoscopies. Other tests include esophageal manometry and pH monitoring.

Once a hiatal hernia is diagnosed, it can be classified into one of four types. Most hiatal hernias are type 1, in which the stomach stays in its usual place, and the hole in the diaphragm sometimes allows a portion of the stomach to slip into it. A healthcare provider will classify the type, perform a differential diagnosis to exclude other causes, and then discuss a treatment option.