Hiatus Hernia

Question 1

What is it?

Answer 1

• The presence of part/ all of the stomach within the thoracic cavity, usually by protrusion through the esophageal hiatus in the diaphragm
• very common
• usually asymptomatic
• May/may not be associated with gastro-esophageal reflux disease(GERD)

Question 2

Risk factor

Answer 2

Obesity

Previous surgeries

Question 3

Clinical presentation

Answer 3

Sliding hernia:

• results from axial displacement of upper stomach through the esophageal hiatus, usually with stretching of the phrenico-esophageal membrane
• most common form
• may result in GERD

Rolling (paraesophageal) hernia:

• results from displacement of part/ all of the fundus and body of the stomach through a defect in the phrenico-esophageal membrane such that it comes to lie alongside the normal esophagus
• much less common
• symptoms: hiccup, pressure in the chest and odynophagia (painful swallowing)
• risk factor for: volvulus (an obstruction caused by twisting of the stomach/intestine), incarceration and obstruction

Question 4

Diagnosis

Answer 4

Barium swallow video usually identifies the type and extent

CT Of the thorax is the investigation of choice in acute presentations

Question 5

Medical Treatment

Answer 5

Medical(mainly for GERD symptoms):

• reduce acid production(stop smoking, lose weight, reduce alcohol consumption)
• counteract acid secretion(PPI, symptomatic relief with antacids)
• promote esophageal emptying(metoclopramide)

Question 6

Surgical treatment

Answer 6

Rarely required
Indicated for:
- persistent symptoms despite maximal medical therapy
- established complications(volvulus/incarceration/obstruction)

Elective procedure of choice = open/laparoscopic reduction of the hernia and fixation ((gastropexy)=stomach is sutured to abdominal wall/diaphragm) usually with plication of the esophageal opening coral plication), occasionally with a fundoplication (nissen’s operation) if GERD symptoms predominate

Acute presentations may require a partial gastrectomy