Hiatal hernias

Question 1

What are the types of hiatal hernias?

Answer 1

• Type I = sliding hernia (95% of all hiatal hernias)

- Type II, III, IV = paraesophageal hernias

Question 2

What is a Type I (sliding) hernia?

Answer 2

• displacement of the gastroesophageal junction above the diaphragm. The stomach remains in its usual longitudinal alignment and the fundus remains below the GE junction.

Question 3

What is a Type II (paraesophageal) hernia?

Answer 3

• a localized defect in the phrenoesophageal membane where the gastric fundus serves as a lead pointof herniation while the GE junction remains fixed to the preaortic fascia and the median arcuate ligament.

Question 4

What is a Type III (paraesophageal) hernia?

Answer 4

• combination of types I and II.

Question 5

What is a Type IV (paraesophageal) hernia?

Answer 5

• a large defect in the phrenoesophageal membrane and is characterized by the presence of organs other than the stomach in the hernia sac (eg. colon, spleen, pancreas, or small intestine).

Question 6

How do you diagnose a hiatal hernia?

Answer 6

• Type I = suspected in pts with symptoms of GERD. Dx via barium swallow, endoscopy, or monometry).
• Types II, III, IV = suspected in pts with a hx of surgical dissection of the hiatus (eg. antireflux procedures, esophagomyotomy, or partial gastrectomy). Dx on upper endoscopy or barium swallow.

Question 7

How do you manage a Type I (sliding) hernia?

Answer 7

• via tx for GERD only

Question 8

How do you manage Types II, III, and IV (paraesophageal) hernias?

Answer 8

• surgery in only symptomatic pts.