Hiatus Hernia

Question 1

Definition

Answer 1

Herniation of part of the stomach (or other organs) through an opening in the diaphragm = oesophageal hiatus.
MC = part of the stomach that connects to the gastro-oesophageal junction
More rarely = the adjacent part of the stomach (paraoesophagus)

Question 2

Types

Answer 2

Type 1 (sliding) = MC
- Gastro-oesophageal junction is displaced upwards
Type 2 = Para-oesophageal
- Parallel migration of part of the stomach in relation to the fixed gasteo-oesophageal junction
Type 3 = Features of type 1 and 2
Type 4 =
- Stomach and other internal organs migrate into the thoracic cavity
- Severe and uncommon
- Other organs include transverse colon, omentum, small bowel or spleenp

Question 3

Epidemiology and Risk factors

Answer 3

• Advancing age: the diaphragmatic muscles weaken over time
• Increasing BMI: increased intra-abdominal pressure from increased adipocity
• Elevated intra-abdominal pressure: BMI, pregnancy, chronic straining and chronic coughing
• Smoking

Question 4

Aetiology and Pathophysiology

Answer 4

Majority acquired. However congenital (termed congenital diaphragmatic hernia) is recognised condition that is screened for in pregnancy during the 20 week USS = this occurs when the oesophageal hiatus is abnormally large, allowing abdominal organs to migrate into the chest and limit the development of the lungs.

Question 5

Signs

Answer 5

Bowel sounds audible in the chest on auscultation

Question 6

Symptoms

Answer 6

Majority Asx. When they do present, similar to GORD
- Epigastric pain
- Heartburn
- Dysphagia
- Nausea and vomiting
- Post-prandial fullness

Question 7

Diagnosis

Answer 7

FIRST LINE = CXR: evidence of stomach or intra-abdominal organs may be visible superior to the diaphragm, a subtle air:fluid level behind the heart on PA film
GOLD STANDARD = Endoscopy = oesophagogastroduodenoscopy
Consider:
- Manometry
- Barium swallow
- CT thorax and abdomen

Question 8

Treatment

Answer 8

Lifestyle modification:
- Small and frequent meals
- Smoking cessation
- Avoid food and drink that trigger heartburn
- Avoid lying down after eating
Medical:
- PPI
Surgery:
- Laproscopic repair: freeing the stomach from the thorax and bringing them into the abdomen. Hiatus sutured to make it narrower
- Nissen’s fundoplication: to reduce risk of reflux = wrap top of stomach around lower part of stomach to strengthen the valve
- Laprotomy = rarely required due to adhesions or previous failed laprascopic attempts

Question 9

Complications

Answer 9

• Pulmonary hypoplasia: (CDH)
• Strangulation
• Severe GORD
• Surgical complications = infection, blood loss, DVT