Hiatus Hernia Flashcards
What is a hiatus hernia?
A hiatus hernia describes the protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus.
This is typically the stomach herniating although rarely small bowel, colon, or mesentery can also herniate through.
How common is hiatus hernia?
Hiatus hernia are extremely common, however the exact prevalence in the general population is difficult to accurately state, simply because the majority are completely asymptomatic.
However it is estimated that around a third of individuals over the age of 50 have a hiatus hernia.
What are the 2 different types of hiatus hernia?
- Siliding hiatus hernia (80%)
- Rolling or Para-Oesophageal hernia (20%)
Briefly describe the pathophysiology of a sliding hiatus hernia
The gastro-oesophageal junction (GOJ), the abdominal part of the oesophagus, and frequently the cardia of the stomach move or ‘slides’ upwards through the diaphragmatic hiatus into the thorax.
A= sliding; B= rolling.
Briefly describe the pathophysiology of a rolling or para-oesophageal hernia
An upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ, which creates a ‘bubble’ of stomach in the thorax. This is a true hernia with a peritoneal sac.
The proportion of the stomach that herniates is variable and may increase with time, eventually may evolve to have almost the entire stomach sitting in the thorax.
A= sliding; B= rolling.
What are the risk factors for developing a hiatus hernia?
Age is the biggest risk factor for developing a hiatus hernia.
Pregnancy, obesity and ascites are also risk factors, due to increased intra-abdominal pressure and superior displacement of the viscera.
Why is age the biggest risk factor in developing a hiatus hernia?
Due to a combination of age-related loss of diaphragmatic tone, increasing intrabdominal pressures (e.g. repetitive coughing and an increased size of diaphragmatic hiatus.
What are the clinical features of a hiatus hernia?
The vast majority of hiatus herniae are completely asymptomatic.
Patients may experience gastroesophageal reflux symptoms, such as burning epigastric pain, which is made worse by lying flat. In patients with a hiatus hernia, these symptoms are often more severe and treatment-resistant.
Other signs and symptoms that can occur include vomiting and weight loss, bleeding and/ or anaemia (secondary to oesophageal ulceration), hiccups or palpitations (if the hiatus hernia is of sufficient size, it may cause irritation to either the diaphragm or the pericardial sac) or swallowing difficulties (either oesophageal stricture formation or rarely incarceration of the hernia).
The clinical examination is typically normal. In patients with a sufficiently large hiatus hernia, bowel sounds may be auscultated within the chest.
What investigations should be ordered for hiatus hernia?
Oesophagogastroduodenoscopy (OGD) is the gold standard investigation, showing upward displacement of the Gastro-Oesophageal Junction (GOJ, also termed the ‘Z-line’).
They can also be diagnosed incidentally, either on a CT or MRI scan. A contrast swallow may also be used to diagnose a hiatus hernia, although are less commonly used
Briefly describe what is shown on the image
An OGD of a Hiatus Hernia, showing upward displacement of the Z-line
Briefly describe the conservative management of a hiatus hernia
The first line pharmacological management for a symptomatic hiatus hernia is a Proton Pump Inhibitor (PPIs), such as omeprazole, acting to reduce gastric acid secretion and aiding in symptom control.
Any patient should be advised of lifestyle modification, including weight loss, alteration of diet (low fat, earlier meals, smaller portions) and sleeping with the head of the bed raised.
Smoking cessation and reduction in alcohol intake should be advised, as both nicotine and alcohol are thought to inhibit lower oesophageal sphincter function, thereby worsening symptoms.
Why do PPIs need to be taken in the morning?
PPIs must be taken in the morning before food, otherwise the drugs’ binding site becomes internalised and are ineffective.
When is surgery indicated in patients with a hiatus hernia?
Surgical management is indicated when:
- Remaining symptomatic, despite maximal medical therapy
- Increased risk of strangulation/volvulus (rolling type or mixed type hernia or containing other abdominal viscera)
- Nutritional failure (due to gastric outlet obstruction)
What are the 2 surgical options when treating a hiatus hernia?
There are two aspects of hiatus hernia surgery:
- Cruroplasty
- Fundoplication
Briefly describe the role of cruroplasty in the management of a hiatus hernia
The hernia is reduced from the thorax into the abdomen and the hiatus reapproximated to the appropriate size. Any large defects usually require mesh to strengthen the repair.
Briefly describe the role of fundoplication in management of a hiatus hernia
The gastric fundus is wrapped around the lower oesophagus and stitched in place.
Aims to strengthen the LOS thus helping to prevent reflux and keep the GOJ in place below the diaphragm- the wrap may be full or partial (usually dependent on surgeon preference).
