Hiatus hernia

Question 1

What is a hiatus hernia?

Answer 1

Protrusion of the upper stomach through the diaphragmatic oesophageal hiatus

Question 2

What are the 3 types of hiatus hernia?

Answer 2

Congenital
Traumatic
Non-traumatic

Question 3

What are the 3 types of non-traumatic hiatus hernia?

Answer 3

Sliding (80%): hernia moves in + out of the chest. Acid reflux often happens as LOS becomes less competent.
Paraoesophageal (rolling, 20%): hernia goes through a hole in the diaphragm next to the oesophagus
Gastro-oesophageal junction remains intact so acid reflux uncommon
Mixed

Question 4

List 5 risk factors for hiatus hernia

Answer 4

Obesity  
Low-fibre diet  
Chronic oesophagitis  
Ascites  
Pregnancy

Question 5

Describe the epidemiology of hiatus hernia

Answer 5

Common in WESTERN countries
Increased frequency with age
70% of pts are > 70 yrs

Question 6

Describe the presentation of hiatus hernia

Answer 6

Most are ASYMPTOMATIC
Sliding hernias more likely to cause sx
NO correlation between size of hernia + severity of the sx
Usually no signs

Question 7

What investigations should be performed in hiatus hernia?

Answer 7

FBC: to identify IDA
BARIUM SWALLOW
CXR: gastric air bubble may be seen above diaphragm
Endoscopy

Question 8

Describe the medical management of hiatus hernia

Answer 8

Modify lifestyle factors (e.g. lose weight)
Inhibit acid production (e.g. PPIs)
Enhance upper GI motility

Question 9

When is surgery performed in hiatus hernia? List 3 approaches

Answer 9

In a MINORITY of pts:
those with complications of reflux disease despite aggressive medical tx or pulmonary complications (e.g. aspiration pneumonia)
those with rolling hernia (as may strangulate)
Nissen Fundoplication
Belsey Mark IV Fundoplication
Hill Repair

Question 10

Desrcribe a Nissen Fundoplication

Answer 10

Stomach is pulled down through the oesophageal hiatus + part of the stomach is wrapped (360 degrees) around the oesophagus to make a new sphincter + reduce likelihood of herniation

Question 11

Describe a Hill Repair

Answer 11

Gastric cardia is anchored to the posterior abdominal wall

Question 12

List 5 oesophageal complications may arise in hiatus hernia

Answer 12

Intermittent bleeding  
Oesophagitis  
Erosions  
Barrett's oesophagus  
Oesophageal strictures

Question 13

What non-oesophageal complications may arise in hiatus hernia?

Answer 13

Incarceration of hiatus hernia (only paraoesophageal hernias)
Can lead to strangulation + perforation

Question 14

What is the prognosis of hiatus hernia?

Answer 14

Generally GOOD

Sliding have a better prognosis than rolling

Question 15

Although uncommon, what sign may present in hiatus hernia?

Answer 15

Bowel sounds in chest