5. Hiatal hernia – GERD Flashcards
Hiatal hernia: Epidemiology
Incidence increases with:
- Age: affects ∼ 70% of people > 70 years
- ↑ BMI
Hiatal hernia: prevalence
Most commonly occur on the left side, as the liver protects the right diaphragm.
Etiology
Multifactorial.
- Lax diaphragmatic esophageal hiatus (obesity)
- Prolonged periods of increased intra-abdominal
pressure - Defects of the pleuroperitoneal membrane
Classification - types
I. sliding (95% of all cases)
II. paraesophageal
III. mixed
IV. complex
Type I hiatal hernia
sliding
- GEJ and cardia slide into posterior mediastinum
- Gastric fundus remains below (hourglass stomach)
Type II hiatal hernia
Paraesophageal
- fundus enters thoraxic cavity
- GEJ remains in anatomical position
Symptoms of type I hiatal hernia
GERD symptoms
Symptoms of type II, III, and IV hiatal hernia
- Epigastric/substernal pain
- Early satiety
- Symptoms of GERD can occur
Diagnostics
Barium swallow: most sensitive test
- Assesses type and size of a hernia
Endoscopy
- used to diagnose hiatal hernia and evaluate for possible complications
Conservative management of hiatal hernia
- Lifestyle modifications
- Proton pump inhibitors
Mainly relevant for type I
Surgical management of hiatal hernia
laparoscopic/open fundoplication + hiatoplasty
Indications for surgery of hiatal hernia
- Persistence of symptoms; conservative management
- Severe symptoms/complications of gastroesophageal reflux disease: bleeding, strictures, ulcerations
GERD pathologies
- Hiatal hernia
- Acidic reflux (gastric content)
- Non-acidic reflux (NERD)
Diagnosis of GERD
From notes:
24h monitoring + DeMeester score (pH, reflux period, etc)
From amboss:
Typical symptoms: Presume GERD diagnosis and start an empiric PPI trial.
Good response: often used to confirm GERD diagnosis
Pharmacological therapy of GERD
PPIs: standard dose of PPI for 8 weeks
