Hiatus Hernia

Question 1

Definition of hernia

Answer 1

Protrusion of a whole or part of an organ through the wall of the cavity that contains it into an abnormal position.

Question 2

What is a hiatus hernia?

Answer 2

Protrustion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus.

Typically the stomach herniating.

It can also be small bowel, colon or mesentery but these are rare

Question 3

Epidemiology

Answer 3

Extremely common but asymptomatic

Around a third of individuals over the age of 50 are believed to have a hiatus hernia

Question 4

Subtypes

Answer 4

Sliding hiatus hernia (80%)

Rolling or para-oesophageal hernia (20%)

Question 5

Explain sliding hiatus hernia

Answer 5

GOJ, the abdominal part of the oesophagus and frequently the cardia of the stomach move or slides upwards through the diaphragmatic hiatus into the thorax.

Question 6

Explain rolloing or para-oesophageal hernia.

Answer 6

Upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ.

It creates a “bubble” of stomach in the thorax and is a true hernia with a peritoneal sac.

Mixed type can also occur.

Question 7

Risk factors

Answer 7

Age is the biggest risk factor due to…
Age-related loss of diaphragmatic tone
Increasing intrabdominal pressures
Increased size of diaphragmatic hiatus

Pregnancy

Obesity

Ascites

Question 8

Clinical features

Answer 8

Usually asymptomatic

Might have GORD symptoms like burning epigastric pain made worse by lying flat.

Vomiting and weight loss, bleeding +/- anaemia

Hiccups or palpitations (irritates the pericardial sac)

Dysphagia

Question 9

Examination findings

Answer 9

Typically normal

If the hernia is large enough bowel sounds may be ausculated in the chest

Question 10

Sometimes gastric outflow can become blocked leading to early satiety, vomiting and nutritional failure.

What needs to be done?

Answer 10

Transfer to nearested oesophago-gastric unit

Question 11

Dx

Answer 11

Cardiac chest pain

Gastric or pancreatic cancer

GORD

Question 12

Investigations

Answer 12

Oesophagogastroduodenoscopy (OGD) is gold standard

Can also be diagnosed incidentaly on CT or MRI scan

Contrast swallow might be done but is not commonly used.

Question 13

OGD findings of hiatus hernia

Answer 13

Upward displacement of GOJ aka Z-line

Question 14

Conservative management

Answer 14

PPis like omeprazole
Should be taken in the morning before food.

Weight loss and alteration of diet

Smoking cessation and reduction in alcohol intake (both nicotine and alcohol are thought to inhibit the LOS)

Question 15

Indications of surgical intervention

Answer 15

Remaining symptomatic despite maximal medical therapy

Increased risk of strangulation/volvulus

Nutritional failure

Question 16

What should be done prior to surgical management in suspected obstruction, strangulation or stomach volvulus?

Answer 16

Stomach decompression via NG tube

Question 17

Types of hiatus hernia surgery

Answer 17

Cruroplasty

Fundoplication

Question 18

Explain cruroplasty

Answer 18

Hernia reduced from thorax into abdomen and hiatus is reapproximated to the appropraite size

Any large defects usually require mesh to strengthen the repair.

Question 19

Explain fundoplication

Answer 19

Gastric fundus is wrapped around the LOS and stitched in place.

This aims to strengthen the LOS to help prevent reflux and keep GOJ in place below the diaphragm.

Question 20

Complications of hiatus hernia surgery

Answer 20

Recurrence of the hernia

Abdominal bloating (inability to belch)

Dysphagia if fundoplication is too tight or if crural repair is too narrow - patient may need revisional surgery

Fundal necrosis (blood supply via left gastric artery and short gastric vessels are disrupted (this is a surgical emergency requiring major gastric resection))

Question 21

Complications of hiatus hernia

Answer 21

Incarceration and strangulation

Gastric volvulus leading to obstruction of gastric passage and tissue necrosis

Question 22

Borchardt’s traid of gastric volvulus

Answer 22

Severe epigastric pain

Retching without vomiting

Inability to pass an NG tube