Hiatus Hernia

Question 1

Define hiatus hernia

Answer 1

protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm. A hiatal hernia most commonly contains a variable portion of the stomach, but it may also contain other organs/ omentum (Giant hiatal hernia)

Question 2

What are the causes/risk factors of hiatus hernias?

Answer 2

• Congenital - increased angle of His
• Traumatic
• Non-traumatic:
- Sliding (80%): The hernia moves in and out of the chest. Acid Reflux occurs due to the reduced competence of the LOS, causing GORD.
- Paraoesophageal (rolling): The gastro-oesophageal junction stays in the abdomen, and it remains competent, making GORD unlikely. A portion of the stomach bulges up into the chest next to the oesophagus
• Mixed

Risk factors:
• obesity
•  age
•  previous gastro-oesophageal procedure
•  pregnancy and increased intra-abdominal pressure
•  low fibre diet
•   chronic oesophagitis
•  ascites

Question 3

What are the signs and symptoms of hiatus hernias?

Answer 3

• heartburn
• regurgitation
• symptoms of GORD

*no signs on examination

Question 4

What investigations are carried out for hiatus hernias?

Answer 4

• CXR - may be normal
- Gair bubble seen above the diaphragm – retrogastric airbubbles
* BARIUM SWALLOW BEST TESTS
• FBC - may show iron-deficiency anaemia.
• OGD - inflammation of the oesophagus and proximal migration of the gastro-oesophageal junction. Cannot reliably exclude
• CT/ MRI - partial or complete intrathoracic stomach and herniation of other intra-abdominal organs into the chest

Question 5

What is the management for hiatus hernias?

Answer 5

Conservative:
• Weight loss

Medical:
• Treat GORD – PPI

Surgical:
• Usually performed in patients with complications of reflux disease despite aggressive medical treatment or pulmonary complications (e.g. aspiration pneumonia)
• Advised to repair rolling hiatus hernia prophylactically, even if asymptomatic, as it may strangulate, which needs prompt surgical repair.
• Nissen Fundoplication
- The stomach is pulled down through the oesophageal hiatus and part of the stomach is wrapped (360 degrees) around the oesophagus to make a new sphincter and reduce the likelihood of herniation
• Belsey Mark IV Fundoplication
- 270 degree wrap
• Hill Repair
- Gastric cardia is anchored to the posterior abdominal wall

Question 6

What are the complications of hiatus hernias?

Answer 6

Oesophageal:
•  Intermittent bleeding  
•  Oesophagitis  
•  Barrett's oesophagus  
•  Oesophageal strictures  

Non-Oesophageal:
• Incarceration of hiatus hernia (only with paraoesophageal hernias) → This can lead to strangulation and perforation
• Aspiration pneumonia