Hiatal Hernia

Question 1

What is the definition of a hiatal hernia?

Answer 1

Protrusion of any abdominal structure/organ into the thorax through a lax diaphragmatic oesophageal hiatus

Question 2

Which age is most common for a hiatal hernia? And which BMI?

Answer 2

> 70 years.
Increased BMI

Question 3

What are some risk factors for a hiatal hernia?

Answer 3

Advanced age
Smoking
Obesity
Generic predisposition (rare)
Pregnancy
As it’s
Chronic cough
Chronic constipation
Defects of the pleuroperitoneal membrane

Question 4

What are the 4 types of hiatal hernias?

Answer 4

Sliding hiatal hernia

Paraoesophageal hiatal hernia

Mixed hiatal hernia

Complex hiatal hernia

Question 5

What happens with a sliding hiatal hernia?

Answer 5

The GEJ and gastric cardia slide up into posterior mediastinum. Gastric funded remains below diaphragm

Question 6

What happens in paraoesophageal hiatal hernia?

Answer 6

Part of gastric find us herniated into the thorax. GEJ remains in its anatomical position below diaphragm

Question 7

What happens in mixed hiatal hernia?

Answer 7

The GEJ and portion of the gastric funds prolapse through the hiatus

Question 8

What happens in complex hiatal hernia?

Answer 8

Herniation of an abdominal structure other than the stomach eg spleen, omentum or colon

Question 9

What is the pathophysiology of a hiatal hernia?

Answer 9

Predisposing factors lead to laxity of the oesophageal hiatus. Relative negative intrathoracic prsssure and lax hiatus lead to herniation of abdominal contents into thorax.

Question 10

What are the clinical features of a hiatal hernia?

Answer 10

Type 1 - symptoms of GERD.
Types 2, 3, 4 - epigastric/substernal oain
Early satiety
Retching
Symptoms of GERD

Question 11

What are the typical symptoms of GERD?

Answer 11

Dysphasia
Odynophagia (sensation of painful swallowing)
Water brash (excessive salivation triggered by refluxing of stomach acid)

Question 12

What is the diagnosis of a hiatal hernia?

Answer 12

Barium swallow

Endoscopy

Chest X-ray

CT thorax

Question 13

Which is the most sensitive diagnostic test for a hiatal hernia? And what does it do?

Answer 13

Barium swallow - assesses type and size kf herbia

Question 14

What is an endoscopy used for in a hiatal hernia?

Answer 14

Used to diagnose hiatal hernia and evaluate possible complications.

Question 15

What is the treatment plan for a sliding hiatal hernia? (Type 1)

Answer 15

Conservative treatment - lifestyle modifications and PPI’s or H2 receptor antagonists

Surgery - laparoscopic/open fundoplication and hiatoplasty

Question 16

What is the management of a type 2,3,4 hiatal hernia?

Answer 16

Conservative - for older patients or those with comorbidities (same as type 1 treatment)

Surgery - laparoscopic/open herniotomy and fundoplication, hiatoplasty, and gastropexy

Question 17

What is a complication of a type 1 hiatal hernia?

Answer 17

Arise from standing GERD - Barrett’s oesophagus, reflux oesophagitis, iron deficiency anaemia, oesophageal stricture, oesophageal ring, reflux laryngitis

Question 18

Complications of type 2,3,4 hiatal hernia?

Answer 18

Upper GI bleeding -> iron deficiency anaemia
Gastric ulcers
Gastric perforations
Gastric volvulus
Total gastric obstruction