Hiatus Hernia Flashcards
What is a hiatus hernia?
protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm
What are the two different types of hiatus hernia?
- Sliding hiatus hernia (80%)
2. Rolling hiatus hernia (20%)
What is a sliding hiatus hernia?
gastro-oesophageal junction slides up into chest – acid reflux happens as lower oesophageal sphincter less competent
What is a rolling hiatus hernia?
gastro-oesophageal junction remains in abdomen but a bulge of stomach herniates up into chest alongside oesophagus, GORD less common as gastroesophageal junction remains intact
What is epid of hiatus hernia?
obese male
What are risk factors for hiatus hernia?
- Obesity
- Previous gastro-oesophageal procedure
- Elevated intra-abdominal pressure
- Male sex
What are the symptoms of a hiatus hernia?
- Heartburn
- Regurgitation
- Chest pain
- Dysphagia
- Bowel sounds in chest
What are differential diagnosis for hiatus hernia
- Angina pectoris
- Gastro-oesophageal reflux disease (GORD)
- Pneumonia
- Gastric outlet obstruction
- Oesophageal motility disorder
- Gastric atonia
What are the initial investigations for hiatus hernia?
GOLD STANDARD:
Upper GI endoscopy
1. CXR
2. Upper gastrointestinal series
What would a CXR show in hiatus hernia?
retrocardiac air bubble or normal
What would upper GI series show in a hiatus hernia?
stomach is partially or completely intrathoracic
What other investigations would you consider for a hiatus hernia?
- OGD
- CT scan or MRI
- Oesophageal manometry and pH monitoring
What would an OGD show in hiatus hernia?
inflammation of the oesophagus and proximal migration of the gastro-oesophageal junction
What would a CT scan or MRI show in hiatus hernia?
partial or complete intrathoracic stomach and herniation of other intra-abdominal organs into the chest
What would oesophageal manometry and pH monitoring show in hiatus hernia?
double hump configuration on manometry, normal or abnormal 24-hour pH
What is the 1st line treatment for upper gastrointestinal (GI) haemorrhage and/or obstruction and/or volvus?
resuscitation and urgent surgical repair
What is the first line treatment for irreversible organ ischaemia and/or necrosis?
surgical resection and supportive care
What is the 1st line treatment for acute symptomatic GORD?
1st line: PPIs
Plus: lifestyle changes (loss weight)
What is the 1st line treatment for ongoing type I refractory to medical therapy or patient prefers surgery?
surgical repair with or without anti-reflux procedure
What is the 1st line treatment for types II,III,IV?
surgical repair with or without anti-reflux procedure
What are the possible complications of a hiatus hernia?
- bloating following surgery
- gastric volvulus
- obstruction
- early recurrent hernia following surgery
- dysphagia following surgery
- post-operative haemorrhage
- fundal necrosis following surgery
- diarrhoea following surgery
- early mesh infection following surgery
- gastrointestinal bleeding
- Barrett’s oesophagus
- late mesh complications following surgery
- late hernia recurrence following surgery
What is the prognosis of a hiatus hernia?
uncomplicated sliding hiatus hernia will have adequate relief of symptoms (but not cure) with medical therapy
What are other symptoms and signs of hiatus hernia?
- Bowel sounds in chest
- Can be asymptomatic
- GORD usually worse when lying flat
- Palpitations or hiccups indicate pericardial irritation
What is the lifestyle and medicinal management of hiatus hernia?
Weight loss and PPI
What surgery is used in treatment of hiatus hernia?
- only refractor to medical therapy
- involves pushing hernia back into abdomen, then stomach is also wrapped around the OJ to help tighten it
