Hiatus Hernia

Question 1

What is a hiatus hernia?

Answer 1

A hiatus hernia refers to the herniation of part of the stomach through the diaphragmatic oesophageal hiatus.

Question 2

Hiatus hernia is an extremely … anatomical abnormality. It refers to the herniation of part of the stomach through an opening in the … known as the oesophageal hiatus. This opening functions to allow the oesophagus to pass through the … into the abdominal cavity.

Answer 2

Hiatus hernia is an extremely common anatomical abnormality. It refers to the herniation of part of the stomach through an opening in the diaphragm known as the oesophageal hiatus. This opening functions to allow the oesophagus to pass through the diaphragm into the abdominal cavity.

Question 3

Do hiatal hernias always cause symptoms? What are they associated with sometimes?

Answer 3

The majority of hiatal hernias are asymptomatic and found incidentally during endoscopy or imaging (e.g. CT or barium swallow). They may be associated with gastro-oesophageal reflux due to disruption of the lower oesophageal sphincter. Management depends on the type of hiatal hernia and associated symptoms.

Question 4

How are hiatal hernias identified?

Answer 4

Hiatal hernias are usually identified as an incidental finding when endoscopy or imaging is being performed for another reason. Traditional risk factors for hiatus hernia include older age, male sex, and obesity. In one study, the prevalence of hiatus hernia was 9.9% among 3200 patients undergoing CT imaging. This number varies greatly depending on the study.

Question 5

Classification of hiatal hernias:

Hiatal hernias can be divided into four main types.

Answer 5

Type I (sliding): displacement of the gastro-oesophageal junction (GOJ) above the diaphragm. Account for >95% of hiatal hernias and usually asymptomatic
Type II (para-oesophageal): herniation of the gastric fundus through a defect in the phrenoesophageal membrane. The GOJ remains below the diaphragm. The least common type of para-oesophageal hernia
Type III (para-oesophageal): a combination of type I and II hernias. Both the gastric fundus and GOJ herniate through the oesophageal hiatus and lie above the diaphragm. The most common type of para-oesophageal hernia
Type IV (para-oesophageal): characterised by the presence of other organs within the hernial sac above the diaphragm (e.g. large bowel, small bowel). Usually, there is significant displacement of the stomach above the diaphragm due to a large defect in the phrenoesophageal membrane. As the stomach herniates through it may twist on its longitudinal or horizontal axis leading to a gastric volvulus

Question 6

Type 1 (sliding) - hiatus hernia

Answer 6

Type I (sliding): displacement of the gastro-oesophageal junction (GOJ) above the diaphragm. Account for >95% of hiatal hernias and usually asymptomatic

Question 7

Type II (para-oesophageal) hiatus hernia:

Answer 7

Type II (para-oesophageal): herniation of the gastric fundus through a defect in the phrenoesophageal membrane. The GOJ remains below the diaphragm. The least common type of para-oesophageal hernia

Question 8

What type of hiatus hernia accounts for over 95% of them? And usually asymptomatic?

Answer 8

Type I (sliding): displacement of the gastro-oesophageal junction (GOJ) above the diaphragm. Account for >95% of hiatal hernias and usually asymptomatic

Question 9

Type III (para-oesophageal): hiatus hernia

Answer 9

Type III (para-oesophageal): a combination of type I and II hernias. Both the gastric fundus and GOJ herniate through the oesophageal hiatus and lie above the diaphragm. The most common type of para-oesophageal hernia

Question 10

Type IV (para-oesophageal): hiatus hernia

Answer 10

Type IV (para-oesophageal): characterised by the presence of other organs within the hernial sac above the diaphragm (e.g. large bowel, small bowel). Usually, there is significant displacement of the stomach above the diaphragm due to a large defect in the phrenoesophageal membrane. As the stomach herniates through it may twist on its longitudinal or horizontal axis leading to a gastric volvulus

Question 11

NOTE: para-oesophageal hernias are sometimes referred to as ‘…’ hiatus hernias.

Answer 11

NOTE: para-oesophageal hernias are sometimes referred to as ‘rolling’ hiatus hernias.

Question 12

Label the hiatus hernias

Answer 12

Question 13

A hiatus hernia is commonly associated with loss of the normal gastro-oesophageal ….

Answer 13

A hiatus hernia is commonly associated with loss of the normal gastro-oesophageal junction.

Question 14

Several risk factors increase the risk of developing a hiatus hernia, which includes; (6)

Answer 14

Obesity
Pregnancy
Trauma
Previous gastro-oesophageal surgery
Increasing age
Congenital defects

Question 15

The oesophagus joins the stomach at the gastro-oesophageal junction (GOJ), which is usually demarcated by the z-line otherwise known as the squamocolumnar junction. The lower end of the oesophagus is tightly bound to the diaphragm by the phrenoesophageal membrane. Food that enters the stomach must pass through the GOJ, which is maintained by two sphincters:

… …. sphincter
… of the …

Answer 15

The oesophagus joins the stomach at the gastro-oesophageal junction (GOJ), which is usually demarcated by the z-line otherwise known as the squamocolumnar junction. The lower end of the oesophagus is tightly bound to the diaphragm by the phrenoesophageal membrane. Food that enters the stomach must pass through the GOJ, which is maintained by two sphincters:

Lower oesophageal sphincter
Crus of the diaphragm

Question 16

Certain risk factors may contribute to the development of a hiatal hernia through … of the oesophageal hiatus, increased … of the phrenoesophageal membrane and … of the oesophagus that pulls the stomach upwards. As the integrity of the GOJ is lost, pathological reflux of gastric contents can occur leading to symptoms of heartburn. In fact, > …% of patients with gastro-oesophageal reflux will have a type I hiatus hernia.

Answer 16

These factors may contribute to the development of a hiatal hernia through widening of the oesophageal hiatus, increased laxity of the phrenoesophageal membrane and shortening of the oesophagus that pulls the stomach upwards. As the integrity of the GOJ is lost, pathological reflux of gastric contents can occur leading to symptoms of heartburn. In fact, > 50% of patients with gastro-oesophageal reflux will have a type I hiatus hernia.

Question 17

What percentage of patients with GORD have a type I hiatus hernia?

Answer 17

In fact, > 50% of patients with gastro-oesophageal reflux will have a type I hiatus hernia.

Question 18

Signs and symptoms of a hiatus hernia (8)

Answer 18

Asymptomatic
Heartburn
Regurgitation
Dysphagia
Epigastric pain
Post-prandial fullness
Nausea
Retching

Question 19

NOTE: patients with …-…. hernias are less likely to experience reflux and more at risk of mechanical complications such as gastric volvulus leading to dysphagia, post-prandial pain and distension

Answer 19

NOTE: patients with para-oesophageal hernias are less likely to experience reflux and more at risk of mechanical complications such as gastric volvulus leading to dysphagia, post-prandial pain and distension

Question 20

How are hiatus hernias diagnosed?

Answer 20

The diagnosis of hiatus hernia is commonly made on imaging or during upper GI endoscopy.

Question 21

Upper GI endoscopy - hiatus hernia

Answer 21

A type I (sliding) hiatus hernia is observed as a >2 cm separation between the z-line and the diaphragmatic impressions. A para-oesophageal hernia may be observed as a portion of the stomach herniating through the diaphragm adjacent to the endoscope.

Question 22

Barium swallow for hiatus hernia: what is the grey star showing?

Answer 22

This involves swallowing barium contrast and observing it travel down the tubular oesophagus and into the stomach. A >2 cm separation between the Z-line (identified by an area known as the B ring) and the diaphragmatic hiatus is consistent with a sliding hiatus hernia. Para-oesophageal hernias will be seen as a displacement of part of the stomach above the diaphragm with or without displacement of the GOJ (depends on type).

Question 23

How may hiatal hernias be seen on a CXR?

Answer 23

Hiatal hernias may be seen on chest x-ray as a retrocardiac mass with or without an air-fluid level. Very large hiatal hernias may give strange appearances on X-rays due to air-fluid levels.

Question 24

… is not conventionally completed for a hiatus hernia unless there is a suspected complication (e.g. gastric volvulus). A hiatus hernia will appear as a retrocardiac mass with or without an air-fluid level.

Answer 24

CT is not conventionally completed for a hiatus hernia unless there is a suspected complication (e.g. gastric volvulus). A hiatus hernia will appear as a retrocardiac mass with or without an air-fluid level.

Question 25

What is the typical management of a hiatal hernia?

Answer 25

The majority of hiatal hernias do not require any intervention - but it depends on the type and any associated complications

Question 26

Intervention for hiatus hernias: overview

Answer 26

As a general rule, asymptomatic type I hiatal hernias do not require any intervention. Patients with symptomatic type I hiatal hernias require management of gastro-oesophageal reflux disease, which includes proton pump inhibitors and in highly selected cases surgery.

In patients with para-oesophageal hernias (Type II-IV), surgical intervention is typically recommended if they are symptomatic or develop complications (e.g. gastric volvulus, strangulation). There are various approaches for surgical repair that can be used (e.g. transabdominal or transthoracic para-oesophageal hernia repair).

Question 27

Patients with symptomatic type I hiatal hernias require management of gastro-oesophageal reflux disease, which includes …. and in highly selected cases …

Answer 27

Patients with symptomatic type I hiatal hernias require management of gastro-oesophageal reflux disease, which includes proton pump inhibitors and in highly selected cases surgery.

Question 28

In patients with para-oesophageal hernias (Type II-IV), … intervention is typically recommended if they are symptomatic or develop complications (e.g. gastric volvulus, S…).

Answer 28

In patients with para-oesophageal hernias (Type II-IV), surgical intervention is typically recommended if they are symptomatic or develop complications (e.g. gastric volvulus, strangulation).

Question 29

What surgical approaches can be used in hiatus hernias?

Answer 29

There are various approaches for surgical repair that can be used (e.g. transabdominal or transthoracic para-oesophageal hernia repair).

Question 30

Complications of a type I hiatus hernia are rare and typically related to the degree of …

Answer 30

Complications of a type I hiatus hernia are rare and typically related to the degree of reflux.

Question 31

Complications of hiatus hernia are more likely to occur in patients with …-… hernias. These may include: (6)

Answer 31

Gastric volvulus
Strangulated hernia
Uncontrolled bleeding
Respiratory compromise
Gastric outlet obstruction
Perforation

Question 32

What are the 6 possible complications of a para-oesophageal hernia?

Answer 32

Gastric volvulus
Strangulated hernia
Uncontrolled bleeding
Respiratory compromise
Gastric outlet obstruction
Perforation