Hiatus hernia

Question 1

What is a hiatus hernia?

Answer 1

Prolapse of the upper stomach through the diaphragmatic oesophageal hiatus- into the thorax

Question 2

What are the 2 types of hiatus hernia a patient could have?

Answer 2

1. Sliding Hiatal Hernia (most common type, 95% of cases) → GOJ moves above the diaphragm.
2. Rolling Hiatal Hernia → GOJ remains below the diaphragm but a separate part of the stomach (eg. Fundus) herniates through the oesophageal hiatus. Needs more urgent treatment as volvulus can result in ischemia and necrosis.

Question 3

What are the risk factors for developing a hiatus hernia?

Answer 3

• obesity
• GORD
• Chronic oesophagitis
• Low- fibre diet
• increased intra-abdominal pressure (pregnancy, ascites, chronic cough or constipation)

Question 4

What are the causes of a hiatus hernia?

Answer 4

1. Congenital
2. Traumatic
3. Non-traumatic
   - Sliding (80%) - the hernia moves in and out of the chest. Acid reflux often happens as the lower oesophageal sphincter becomes less competent.
   - Paraoesophageal (rolling, 20%) - the hernia goes through a hole in the diaphragm next to the oesophagus

Question 5

Summarise the epidemiology of hiatus hernia

Answer 5

• Common in WESTERN countries
• Increased frequency with age
• 70% of patients are > 70 yrs
• Particularly common in older obese women
• 50% have symptomatic gastro-oesophageal reflux

Question 6

What are the presenting symptoms of hiatus hernia?

Answer 6

1. Most are ASYMPTOMATIC
2. GORD symptoms + painless regurgitation = hiatus hernia
3. Patients may present with symptoms of GORD:
   - Heartburn
   - Waterbrash:when an excessive amount of saliva occurs and mixes with stomach acids that have risen to the throat. It can cause a bad taste in the mouth and lead to heartburn.
4. NO correlation between the size of the hernia and severity of the symptoms

Question 7

What signs of hiatus hernia can be found on physical examination?

Answer 7

Usually NO SIGNS

Question 8

What investigations are used to diagnose/ monitor a hiatus hernia?

Answer 8

1. Bloods: FBC - check for iron deficiency anaemia
2. Barium Swallow → assesses type & size of hernia. Most sensitive test.
3. Upper GI Endoscopy → given nature of symptoms, most patients have this first line, with hiatus hernia being found incidentally.
4. CXR → retrocardiac bubble

Question 9

How is a hiatus hernia managed?

Answer 9

1. Conservative Management → weight loss and PPI’s (4-8 wks)
2. Surgery (mainly for rolling) → laparoscopic/open fundoplication (Nissen Fundoplication) and hiatoplasty (if symptoms persist despite conservative management)

Question 10

What complications may arise following a hiatus hernia?

Answer 10

1. Oesophageal
   - Intermittent bleeding
   - Oesophagitis
   - Erosions
   - Barrett’s oesophagus
   - Oesophageal strictures
2. Non-Oesophageal
   - Incarceration of hiatus hernia (only with paraoesophageal hernias)
   - This can lead to strangulation and perforation

Question 11

Summarise the prognosis for patients with hiatus hernia

Answer 11

• Generally GOOD
• Sliding hernias have a better prognosis than rolling hernias