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The term "hiatal hernia" refers to an abnormality in anatomy, not to a disease process. As such, many people have hiatal hernias, both large and small, without having any symptoms. However, for people with gastroesophageal reflux, a hiatal hernia can be a factor in the severity of their symptoms, as the herniated portion of stomach serves as a trap for acidic stomach fluids. As such, a hiatal hernia is usually diagnosed as a result of an investigation into the cause of reflux, or other problems such as chest pain, breathing problems, or difficulty swallowing.
Techniques used in the diagnosis of gastroesophageal reflux, however, are not always useful in demonstrating the presence of hiatal hernia. For example, a "sliding" hiatal hernia is one in which the junction between esophagus and stomach, as well as a portion of the stomach, is above the diaphragm. It may appear on plain chest x-rays as only a slight enlargement of the esophagus above the diaphragm. The enlargement, if seen, is generally not diagnostic. By contrast, a paraesophageal hiatal hernia may appear as two structures, with a portion of the stomach protruding above the diaphragm next to the esophagus.
 While a plain chest x-ray may suggest the presence of a hernia, it is important to remember that a hiatal hernia, by itself, is not always a health problem. Therefore, a person who is having symptoms associated with reflux may have several diagnostic tests performed to determine the cause and plan appropriate treatment. The tests most likely to uncover a hiatal hernia include a barium upper gastrointestinal series, or barium-swallow x-rays and upper endoscopy.
Barium-Swallow X-rays
Using barium as a contrast medium yields a clearer image than plain chest x-rays. It shows the contours and alignment of the esophagus and stomach and allows the doctor to see anatomic variations from normal. This technique is especially useful when there is a paraesophageal hernia, but is not always definitive in identifying a sliding hernia.
Upper Endoscopy
A more definitive examination of the anatomy in question is afforded by upper endoscopy, a technique that allows direct visualization of the gastroesophageal structures, as well as the first portion of the small intestine. It is performed by insertion of a lighted, flexible tube through the mouth or nostril into the esophagus, stomach and then the small intestine. This technique also permits the physician to examine the tissues lining the gastroesophageal structures and often is used to obtain a biopsy for further study of a particular problem. Confirmation of the presence of a hiatal hernia is usually made as the endoscope approaches the stomach or as it is being withdrawn from the stomach and enters the esophagus. In some cases, the doctor may ask a patient to "sniff" as the scope is being moved to see if there is a change in the size of opening, or lumen, of the esophagus.
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