Flashcards in Paraesophageal hernia Deck (26):
What is hiatal hernia type is more likely to present with symptoms of obstruction: a sliding (type I) or paraesophageal (type II)?
What is the pathology seen in a type I hiatal hernia?
An attenuated phrenoesophageal ligament, there is no true hernia sac
What is the most common hiatal hernia?
Type I (sliding)
Are hiatal hernias more common in women or men?
Women, and more common in the 5th-6th decade.
Where is the GE junction in a true type II hiatal hernia?
Where is the GE junction in a type I hiatal hernia?
What are the clinical and radiographic findings concerning for a paresophageal hiatal hernia?
In ability to pass an NG tube, CXR showing air fluid levels in the mediastinum.
A 58 year old patient presents with acute onset of chest pain, nausea and retching. CXR shows an air fluid level in the mediastinum, and you are unable to pass an NG tube. What is the diagnosis and definitive management?
This patient is presenting with classic findings of Borchardt's triad: chest pain, retching with inability to vomit, and inability to pass an NG tube. The diagnosis is an incarcerated paraesophageal hernia, and is a surgical emergency.
What is a type III hiatal hernia?
Combination of Type I and II, with in intrathoracic GE junction AND herniation of gastric fundus and body into the chest.
What percentage of patients with type II hiatal hernias present with anemia?
Up to one third
Anemia in type II hiatal hernias is caused by what?
Linear ulceration of the gastric cardia resulting from the proximal stomach's repetitive movement across the diaphragm.
What percentage of patients will have resolution of anemia after surgical correction of hernia?
Are 24 hr pH monitoring and motility studies useful for type II or III hernias in the workup of hiatal hernias?
No. the distortion of the GEJ and distal esophagus makes motility studies difficulty to interpret.
When is repair generally recommending for hiatal hernias?
In symptomatic patients, esophageal mucosal damage (esophagitis/Barrett's), or anemia, and in select asymptomatic patients.
What is a Type I hiatal hernia?
What is a type IV hiatal hernia?
Combo hernia with herniation of gastric fundus, body and other intraabdominal organs (colon, spleen, small bowel)
Where is the location of type III and IV hernias?
When symptomatic, how does type I hiatal hernia typically present?
GERD symptoms (mostly heartburn and regurgitation)
When symptomatic, how do type II and III hernias typically present?
Epigastric or chest pain, postprandial discomfort or fullness, abdominal bloating, dysphagia, or respiratory symptoms.
What causes the symptoms experienced in patients with type II or III hiatal hernias?
Hiatal outflow restriction, altered gastric anatomy and distension of intrathoracic portion of the stomach with esophageal or pulmonary compression.
What is the traditional view regarding repair of type II or III hiatal hernias?/
All type II or III hernias should undergo surgical repair regardless of symptoms, due to increased mortality rate.
Is the presence of a type I hiatal hernia an indication for surgery?
No. Most patients with type I hiatal hernia are asymptomatic. However, those with symptoms of GERD, chest pain, dysphagia may benefit from repair.
What are the important operative points in repair of hiatal hernia?
Adequate esophageal dissection to establish adequate esophageal length, return GEJ to intraabdominal position, resection of hernia sac, reduction of herniated content to anatomically correct position, repair hiatal defect.
What is the work up for hiatal hernia?
CXR, or contrast esophagram, EGD (to assess distal esophagus and stomach for concomitant pathology)
Should antireflux procedures accompany all hiatal hernia repairs?
No. Of benefit in type I hernias who present with symptoms of severe GERD, but controversy in type II, because most patients do not have symptoms.