hiatus hernia

Question 1

what is it

Answer 1

A hiatus hernia occurs when abdominal contents protrude through an enlarged oesophageal hiatus in the diaphragm.

Question 2

2 types

Answer 2

Sliding hiatal hernia (80%): The gastro-oesophageal junction slides up into the chest. A less competent sphincter results in acid reflux. Treatment is similar as for GORD.
Rolling hiatal hernia (20%): The gastro-oesophageal junction remains in the abdomen but part of the stomach protrude into the chest alongside the oesophagus. This type needs more urgent treatment as volvulus can result in ischemia and necrosis.

Question 3

rf

Answer 3

Obesity
Previous hiatal surgery
Increased intra-abdominal pressure (such as chronic cough, multiparity or ascites)

Question 4

sx

Answer 4

Symptoms include heartburn, dysphagia, regurgitation, odynophagia, shortness of breath, chronic cough and chest pain.

Hiatal hernias can be diagnosed using barium swallows (upper GI series), which is the most sensitive method, endoscopy and oesophageal manometry.

Question 5

mx

Answer 5

Conservative management
Conservative management includes crucial lifestyle changes. Lifestyle advice for patients with hiatal hernia includes:

Lose weight
Elevate the head of the bed
Avoid large meals and eat 3-4 hours before bedtime
Avoiding alcohol and acidic foods
Avoid smoking as nicotine relaxes the lower oesophageal sphincter (as can chocolate, peppermint, caffeine, fatty foods, and medications such as calcium-channel blockers, nitrates, and beta-blockers)
Medical management
Medical management involves PPI use for 4-8 weeks before assessing response.

Surgical management
Surgical management includes Nissen’s fundoplication in cases of medication-resistance or patient preference. This involves closing the defect by tightening the crura and wrapping the gastric fundus around the lower oesophageal sphincter. Urgent surgery is required if there is haemorrhage, volvulus, ischaemia, necrosis or obstruction.