Hiatus Hernia

Question 1

what is the typical presentation of hiatus hernia?

Answer 1

GORD symp + painless regurg

Question 2

Define a hiatus hernia?

Answer 2

Protrusion of the upper stomach through the diaphragmatic oesophageal hiatus

Question 3

explain the aetiology of a hiatus hernia?

Answer 3

Congenital

Traumatic

Non-traumatic

• Sliding(80%) - the hernia moves in and out of the chest. Acid refluxoften 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-> Gastro-oesophageal junction remains intact so acid reflux uncommon
• Mixed

Question 4

what are the risk factors of a hiatus hernia?

Answer 4

Obesity

Low-fibre diet

Chronic oesophagitis

Ascites

Pregnancy

Muscle weakening and loss of elasticity with age

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 a hiatus hernia?

Answer 6

Most are ASYMPTOMATIC

GORD symptoms + painless regurgitation= hiatus hernia

Patients may present with symptoms of GORD

• Heartburn
• Waterbrash

NO correlation between the size of the hernia and severity of the symptoms

Some uncommon symptoms include: chest pain, dysphagia, odynophagia, SOB, cough

Question 7

what are the signs of a hiatus hernia on physical examination?

Answer 7

Bowel sounds in chest (but uncommon)

Question 8

what are the appopriate investigations for hiatus hernias?

Answer 8

Radiology

CXR (first line) - gastric air bubble may be seen above the diaphragm

Barium swallow- best diagnostic tests

CT/ MRI to consider if pathology not clear or other pathology expected

Question 9

what investigations would you consider for hiatus hernia?

Answer 9

Upper GI endoscopy visualises the mucosa to detect oesophagitis but cannot reliably exclude a hiatus hernia

Question 10

what is the medical management of hiatus hernia?

Answer 10

Modify lifestyle factors (e.g. lose weight)

Inhibit acid production (e.g. PPIs)

Enhance upper GI motility

Question 11

what is the surgical management of a hiatus hernia?

Answer 11

Necessary in a MINORITY of patients

Usually performed in patients with complications of reflux disease despite aggressive medical treatment or pulmonary complications (e.g. aspiration pneumonia)

Advised to repair rolling (para-oesophageal) hiatus hernia prophylactically, even if asymptomatic, as it may strangulate, which needs prompt surgical repair.

Nissen Fundoplication – main one to know about

• 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 12

what are the oesophageal complications of a hiatus hernia?

Answer 12

• Haematemesis
• Intermittent bleeding
• Oesophagitis
• Erosions
• Barrett’s oesophagus
• Oesophageal strictures

Question 13

summarise the prognosis for patients with hiatus hernia?

Question 14

what are the non-oesophageal complications of a hiatus hernia?

Answer 14

• Incarceration of hiatus hernia (only with paraoesophageal hernias)
• This can lead to strangulation and perforation

Question 15

what are the post-op complications of a hiatus hernia?

Answer 15

• Bloating – usually resolves itself
• Dysphagia – doesn’t last too long
• Hemorrhage
• Infection

Question 16

what is nissen fundoplication?

Answer 16

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