Hiatus hernia

Question 1

What is Hiatus hernia?

Answer 1

• protrusion of organ from the abdominal cavity into the thorax through the oesophageal hiatus

Question 2

What organs can herniate through oesophageal hiatus?

Answer 2

• stomach (common)
• small bowel
• colon
• mesentery

Question 3

How common is HH?

Answer 3

• about 1/3 of adults >50 have HH

Question 4

What is the classifictaion for HH?

Answer 4

• Sliding HH (80%)
  
  • cardia moves upwards through hiatus
• Rolling hernia (20%)
  
  • true hernia
  • fundus moves upwards

Question 5

What are the RF of developing a HH?

Answer 5

• Age - loss of diaphragmatic tone
• Pregnancy
• Obesity
• Ascites

Question 6

What are the cf of HH?

Answer 6

• asymptomatic (majority)
• GOR sx
  
  • burning epigastric pain, worse lying flat
• Haematemesis
• Hiccups
• Palpitation
• Dysphagia
• Blocked gstric outflow
  
  • Early satiety, vomiting, nutritional failure

Question 7

What are the DD of HH?

Answer 7

• Cardiac chest pain
• Gastric or pancreatic cancer
• Gastro-oesophageal reflux disease

Question 8

What Ix would you order for HH?

Answer 8

• OGD - gold standard
• contrast swallow (not commonly use)
• Incidental findings on
  
  • CT
  • MRI

Question 9

How would you mx HH conservatively?

Answer 9

• PPI
• Lifestyle modification
  
  • weight loss, low fat, earlier meals, smaller portions, and sleeping with the head of the bed raised.
• Smoking cessation and reduction in alcohol intake - both inh. LOS function

Question 10

What are the surgical Mx of HH?

Answer 10

Stomach decompression - NG tube prior to surgery

• Cruroplasty
  
  • hernia is reduced from the thorax into the abdomen and the hiatus reapproximated to the appropriate size
• Fundoplication
  
  • gastric fundus is wrapped around the lower oesophagus and stitched in place

Question 11

When is surgical mx indicated in HH?

Answer 11

• 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)

Question 12

What are the cx of HH?

Answer 12

• Incarceration and strangulation (rolling type)

Question 13

How does gastric volvulus present?

Answer 13

Borchardt’s triad:

• Severe epigastric pain
• Retching without vomiting
• Inability to pass an NG tube