A hiatus hernia, the presence of the abdominal oesophagus and of a loculus of stomach in the chest, is often associated with irritation of the oesophageal epithelium by gastric contents leaking back. Such reflux can occur without herniation, and herniation also occurs without reflux. The patient is rarely aware that stomach is present in the chest and the severity of the symptoms is not proportional to the amount of stomach that can be seen there radiologically nor to the presence or absence of oesophagitis seen endoscopically. Routine fluoroscopy may fail on one occasion, but on another succeed in demonstrating herniation or reflux in patients with quite definite symptoms. The first step in the diagnosis of hiatus hernia is to believe the patient; normal radiological findings do not exclude hiatus hernia or reflux. Although symptoms such as abdominal or retrosternal discomfort, and relationship to posture, meals and swallowing may be typical, unexpected presentations sometimes prevent physicians from making a firm diagnosis.
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