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A - MSRA Gastrointestinal [7] > [23] Hiatus Hernia > Flashcards

[23] Hiatus Hernia Flashcards

1
Q

What is a hernia defined as?

A

A protrusion of a whole or part of an organ through the wall of a cavity that contains it, into an abnormal position

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2
Q

What is a hiatus hernia?

A

A protrusion of an organ from the abdominal cavity through the oesophageal hiatus

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3
Q

What organ may protrude through the oesophageal hiatus in a hiatus hernia?

A

It is typically the stomach, however rarely can be the small bowel, colon, or mesentery

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4
Q

Are hiatus hernias common?

A

Yes, extremely so

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5
Q

Why is the exact prevalence of hiatus hernias in the population difficult to accurately state?

A

Because the vast majority are completely asymptomatic

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6
Q

What proportion of individuals over 50 have a hiatus hernia?

A

Around a third

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7
Q

What are the other types of diaphragmatic hernias?

A

Congenital

Traumatic

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8
Q

What can hiatus hernias be classified into?

A

Sliding hiatus hernias

Rolling or para-oesophageal hernias

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9
Q

What happens in a sliding hiatus hernia?

A

The gastro-oesophageal junction, the abdominal part of the oesophagus, and frequently the cardia of the stomach move or ‘slides’ upwards through the diaphragmatic hiatus into the thorax

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10
Q

What % of hiatus hernias are sliding?

A

80%

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11
Q

What happens in a rolling or para-oesophageal hiatus hernia?

A

An upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ, which creates a ‘bubble’ of stomach in the thorax

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12
Q

Is a rolling hiatus hernia a true hernia?

A

Yes, with a peritoneal sac

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13
Q

How much of the stomach herniates in a rolling hiatus hernia?

A

Variable

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14
Q

What may happen to the amount of stomach that herniates in a rolling hernia over time?

A

It may increase, eventually to the point where almost the whole stomach is sitting in the thorax

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15
Q

What is a mixed-type hiatus hernia?

A

One that has both a rolling and sliding component

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16
Q

What are the risk factors for the development of a hiatus hernia?

A

Age
Pregnancy
Obesity
Ascites

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17
Q

Which is the biggest risk factor for hiatus hernias?

A

Age

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18
Q

Why does the risk of hiatus hernias increase with age?

A

Because of a combination of age-related loss of diaphragmatic tone, increasing intra-abdominal pressure, and increased size of diaphragmatic hiatus

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19
Q

Why are pregnancy, obesity, and ascites a risk factor for hiatus hernias?

A

Due to increased intra-abdominal pressure and superior displacement of the viscera

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20
Q

What is true of the vast majority of hiatus hernias?

A

They are completely asymptomatic

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21
Q

How might a hiatus hernia present?

A 
Gastroesophageal reflux symptoms
Vomiting and weight loss
Bleeding and/or anaemia
Hiccups or palpitations
Swallowing difficulties
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22
Q

What gastroesophageal reflux symptoms might a hiatus hernia present with?

A

Burning epigastric pain, which is made worse by lying flat

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23
Q

How do the reflux symptoms caused by hiatus hernias vary to those caused by other things?

A

They are often more severe and treatment resistant

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24
Q

What is the importance of vomiting and weight loss as a presentation of hiatus hernia?

A

It is a rare but serious presentation

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25
Q

What causes bleeding and/or anaemia in hiatus hernias?

A

Oesophageal ulceration

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26
Q

How can hiatus hernias cause hiccups or palpitations?

A

If the hiatus hernia is of sufficient size, it may cause irritation to the diaphragm or pericardial sac

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27
Q

How can a hiatus hernia lead to swallowing difficulties?

A

Either through oesophageal stricture formation, or rarely due to incarceration of the hernia

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28
Q

What is found on clinical examination with a hiatus hernia?

A

It is typically normal

In patients with a sufficiently large hiatus hernia, bowel sounds may be auscultated within the chest

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29
Q

Why is vomiting and weight loss a serious presentation?

A

Because it may represent a blockage of gastric outflow,, sometimes intermittent, which results in early satiety, vomiting, and nutritional failure

30
Q

What happens if a patient is suspected to have a blocked gastric outflow due to hiatus hernia?

A

They need to be transferred to the nearest oesophago-gastric unit

31
Q

What are the important differentials to exclude in a patient with suspected hiatus hernia?

A

Cardiac chest pain
Gastric or pancreatic cancer
Gastro-oesophageal reflux disease

32
Q

When in particular is it important to rule out gastric and pancreatic cancer in suspected hiatus hernia?

A

When there is evidence of gastric outlet obstruction, early satiety, or weight loss

33
Q

What are the symptoms of pancreatic cancer?

A

The symptoms are usually vague and non-specific, and include vague abdominal pain and nausea
Weight loss and malaise are usually late symptoms, and are evidence of advanced disease

34
Q

What is the gold standard investigation for hiatus hernia?

A

Oesophagogastroduodenoscopy (OGD)

35
Q

What will an OGD show in hiatus hernia?

A

Upward displacement of the gastro-oesophageal junction (GOJ, also termed ‘Z-line’)

36
Q

How can hiatus hernias be diagnosed incidentally?

A

Either on CT or MRI scan

37
Q

What is the role of contrast swallow in hiatus hernia?

A

It can be used to diagnose, however is less commonly used

38
Q

What investigation is mandatory if there are symptoms of gastric outflow obstruction or weight loss, whereby an upper GI malignancy may be suspected?

A

An urgent CT thorax and abdomen

39
Q

What is the first-line pharmacological management for symptomatic hiatus hernisa?

A

PPIs, such as omeprazole

40
Q

What is the purpose of PPIs in hiatus hernias?

A

They act to reduce gastric acid secretion and aid in symptom control

41
Q

When should PPIs be taken?

A

In the morning before food

42
Q

Why should PPIs be taken in the morning before food?

A

Because otherwise the drugs binding site becomes internalised and are ineffective

43
Q

What advise should any patient with a hiatus hernia be given?

A

On lifestyle modifications

44
Q

What lifestyle modifications can be made to help with the symptoms of hiatus hernias?

A

Weight loss
Alteration of diet - low fat, earlier meals, smaller portions
Potentially sleeping with increased number of pillows
Smoking cessation
Reduction in alcohol intake

45
Q

Why is smoking cessation and reduction in alcohol intake recommended in hiatus hernias?

A

Because both nicotine and alcohol are thought to inhibit lower oesophageal sphincter function, thereby worsening symptoms

46
Q

When is surgical management of a hiatus hernia indicated?

A

Patients who remain symptomatic despite maximal medical therapy
Patients at increased risk of strangulation/volvulus
Nutritional failure

47
Q

Which hiatus hernias are at increased risk of strangulation/volvuli?

A

Rolling type or mixed type hernias, or containing other adbominal viscera

48
Q

What causes nutritional failure in hiatus hernias?

A

Gastric outlet obstruction

49
Q

What should happen to any patients with suspected case of obstruction, strangulation, or stomach volvulus caused by hiatus hernia before surgical intervention?

A

They should have their stomach decompressed by NG tube prior to surgical intervention

50
Q

What are the aspects of hiatus hernia surgery?

A

Cruroplasty

Fundoplication

51
Q

What happens in cruroplasty?

A

The hernia is reduced from the thorax into the abdomen, and the hiatus is reapproximated to the appropriate size

52
Q

What do any large defects usually require in cruroplasty?

A

Mesh to strengthen the repair

53
Q

What happens in fundoplication?

A

The gastric fundus is wrapped around the lower oesophagus and stitched in place

54
Q

What is the aim of fundoplication?

A

To strengthen the LOS, thus helping to prevent reflux and keep the gastro-oesophageal junction in place below the diaphragm

55
Q

Is the wrap full or partial in fundoplication?

A

Can be either, depending on surgeon preference

56
Q

What is the success rate of hernia repair?

A

Excellent, with some centres reporting that >90% of patients have good long term outcomes

57
Q

What are the complications of hiatus hernia repair?

A

Recurrence of the hernia
Abdominal bloating
Dysphagia
Fundal necrosis

58
Q

Why can hiatus hernia repair cause abdominal bloating?

A

Due to in ability to belch, secondary to the improve anti-reflux mechanism of the procedure

59
Q

When can hiatus hernia repair cause dysphagia?

A

If the fundoplication is too tight, or if the crural repair is to narrow

60
Q

Why is dysphagia relatively common after hiatus hernia repair surgery?

A

Due to oedema

61
Q

What happens to the dysphagia occurring after surgery for hiatus hernia repair?

A

If settles to a variable degree in the majority of patients, but in some may need revision surgery

62
Q

How can hiatus hernia repair surgery cause fundal necrosis?

A

If the blood supply via the left gastric artery and short gastric vessels have been disrupted

63
Q

How is fundal necrosis managed?

A

It is a surgical emergency, typically requiring major gastric resection

64
Q

What are hiatus hernias prone to?

A

Incarceration and strangulation

65
Q

Which type of hiatus hernia are particularly prone to incarceration and strangulation?

A

Rolling

66
Q

What happens in a gastric volvulus?

A

The stomach twists on itself by 180 degrees

67
Q

What does a gastric volvulus lead to?

A

Obstruction of the gastric passage and tissue necrosis

68
Q

How is a gastric volvulus managed?

A

It requires prompt surgical intervention

69
Q

How does a gastric volvulus present?

A

Borchardt’s triad

70
Q

What is Borchardt’s triad?

A

Severe epigastric pain
Retching without vomiting
Inability to pass an NG tube

A - MSRA Gastrointestinal [7] (44 decks)

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