Hiatus Hernia

Question 1

Define hiatus hernia.

Answer 1

Hiatus hernia is the protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm, usually containing a variable portion of the stomach.

Less commonly, it may contain transverse colon, omentum, small bowel, or spleen, or some combination of these organs.

All herniated contents are usually contained within a sac of peritoneum.

Question 2

Which type of hernia is most common?

Answer 2

Sliding - type I

Accounts for 90-95% of all cases

Question 3

How common are sliding hiatus hernias?

Answer 3

Present in 30% of people over 50 years

Question 4

Describe a sliding hiatus hernia.

Answer 4

The oesophageal–gastric junction and part of the stomach ‘slide’ through the hiatus so that it lies above the diaphragm.

Question 5

What is a rolling or para-oesophageal hernia?

Answer 5

• Part of the fundus of the stomach prolapses through the hiatus alongside the oesophagus.
• The lower oesophageal sphincter remains below the diaphragm and remains competent

Question 6

What is the aetiology of hiatus hernias?

Answer 6

Unknown

But oesophagus shortens during swallowing secondary to contraction of its longitudinal muscle layer. This in combination with elevations in IAP e.g. coughing, straining, exercise can move distal oesophagus through the oesophageal hiatus into posterior mediastinum.

Question 7

What is the pathophysiology of a hiatus hernia?

Answer 7

Displacement of the gastro-oesophageal junction above diaphragm decreases LOS pressure so the damaged anti-reflux mechanism predisposes to GORD. This is the most common symptom of a sliding hiatus hernia.

In the relatively uncommon (~20%) paraoesophageal hiatus hernias , rotation and migration of the stomach into the chest can produce intermittent strangulatiuon and obstruction and ischaemia. This leads to pain, vomiting, ulcers and necrosis.

Question 8

How are hiatus hernias classified?

Answer 8

• Type I- sliding hiatus hernia
• Type II - pure paraoesophageal/rolling hernia
• Type III - mixed type I and II - fundus or body of stomach have herniated into chest and the gastro-oesophageal junction has also herniated into chest but rests below the herniated stomach
• Type IV - giant hiatus hernia or occurrence of any type of hernia with herniation of one of more other organs such as colon, small bowel, omentum and spleen.

Question 9

What are the risk factors for developing a hiatus hernia?

Answer 9

• Obesity

Other:

• Previous gastro-oesophageal procedure
• Elevated IAP
• Male sex
• Abnormalities of the oesophageal hiatus or the phreno-oesophageal ligaments - weakness/malformations but there is no prototypical anatomical variant that predisposes to it
• Incisional, umbilical or inguinal hernia
• Disorder of collagen metabolism - lacks supportive data
• Old age

Question 10

What is a typical presentation of hiatus hernias?

Answer 10

• Heartburn
• Regurgitation
• Obesity

Other:

• Chest pain
• Dysphagia
• Odynophagia
• Haematemesis (if more than 55cc may represent a complicated hiatus hernia)
• SOB
• Cough
• Otropharyngitis
• Non-bilious vomiting

Question 11

Which type of hernia presents with no symptoms?

Answer 11

Sliding hiatus hernia

Produces no symptoms – any symptoms are due to reflux

Question 12

What are the signs of hiatus hernia on examination?

Answer 12

• Oropharyngitis (secondary to reflux of gastric contents)
• Wheezing (secondary to aspiration of refluxate)
• Decreased left chest breath sounds
• Dullness to thoracic percussion
• Presence of bowel sounds in the left chest.

If complicated:

• Pyrexia
• Tachycardia
• Hypotension
• Tachypnoea
• Altered mental status
• Some or all of the signs elicited with uncomplicated hiatus hernia

Question 13

What investigations would you do for a hiatus hernia?

Answer 13

• CXR - retrocardiac air bubble or normal
• Contrast UGI series
• OGD - checks for oesophagitis but can be misleading
• CT or MRI - helps determine whether other organs have migrated up
• Oesophageal manometry and pH monitoring - for monitoring in patients with atypical symptoms. Double hump pattern on manometry and abnormal pH results only with larger hiatus hernias.

Question 14

What is the management of hiatus hernias?

Answer 14

Type I refractory to medical therapy or patient prefers surgery → surgical repair +/- anti-reflux procedure

Types II, III, IV - surgical repair with or without anti-reflux procedure

GORD - lifestyle modifications, PPI

UGI haemorrhage +/- obstruction +/- volvulus - resuscitation and urgent surgical repair

Irreversible organ ischaemia +/- necrosis - surgical resection and supportive care

Question 15

When does a rolling hiatus hernia produce pain?

Answer 15

Occasionally, severe pain occurs due to volvulus or strangulation

Question 16

Should you repair a hiatus hernia?

Answer 16

Surgery should never be performed for a hiatus hernia alone. The best predictors of a good surgical result are typical reflux symptoms with documented acid reflux, which correlates with symptoms and response to a PPI.

Surgery indications: intractable symptoms despite aggressive medical therapy, complications.

Question 17

What is a major complication of paraoesophagea hernias?

Answer 17

May strangulate but risk dramatically drops after 65yrs

Operative mortality is ~1-2% so prophylactic repair is only undertaken in those at high risk

Question 18

What can the pain from strangulation of a rolling hernia be confused with?

Answer 18

Pain from a para-oesophageal hernia can easily be mistaken for angina pectoris.

Question 19

What are the complications of a hiatus hernia?

Answer 19

• Gastric volvulus
• Obstruction
• Barrett’s oesophagus

Post surgery:

• Bloating
• GI bleeding
• Diarrhoea
• Dysphagia
• Mesh infection
• Fundal necrosis - usually with ligation of short gastric vessels
• Recurrence

Question 20

What is the prognosis of hiatus hernias?

Answer 20

Most patients with an uncomplicated sliding hiatus hernia will have adequate relief of symptoms (but not cure) with medical therapy.

Surgical correction of a hiatus hernia with a relatively small oesophageal hiatus (approximately ≤5 cm) for which medical therapy has failed will have a good to excellent long-term outcome in about 90% of cases.

Question 21

Which type of surgery is done for hiatus hernias?

Answer 21

Nissen fundoplication -anti-reflux procedure

Laparoscopic

Sometimes mesh repair is done