Hiatus Hernia Flashcards
What is a hernia?
Protrusion of a whole or part of an organ through the wall of the cavity that contains it into an abnormal position
What is a hiatus hernia?
The protrusion of an organ from the abdominal cavity into the thorax though the oesophageal hiatus.
Typically the stomach
What are the types of hiatus hernia?
Sliding hiatus hernia - the gastro-oesophageal junction, the abdominal part or the oesophagus and frequently the cardia of the stomach slides up through the diaphragmatic hiatus into the thorax.
- Acid reflux often happens as the lower oesophageal sphincter becomes less competent.
Rolling or para-oesophageal hernia - upward movement of the gastric fundus occurs to lie alongside a normally positioned gastro-oesophageal junction, which creates a bubble of stomach in the thorax. This is a true hernia with a peritoneal sac
What is a sliding hiatus hernia?
the gastro-oesophageal junction, the abdominal part or the oesophagus and frequently the cardia of the stomach slides up through the diaphragmatic hiatus into the thorax.
- Acid reflux often happens as the lower oesophageal sphincter becomes less competent.
What is a rolling hiatus hernia?
upward movement of the gastric fundus occurs to lie alongside a normally positioned gastro-oesophageal junction, which creates a bubble of stomach in the thorax. This is a true hernia with a peritoneal sac. GORD is less common
What are risk factors for hiatus hernia?
Age - age related loss of diaphragmatic tone, increasing intraabdominal pressures and increased size of diaphragmatic hiatus.
Pregnancy
Obesity
Ascites
- all due to increased intra-abdominal pressure and superior displacement of viscera
What are the clinical features of hiatus hernia?
Mostly asymptomatic
May develop GORD - burning epigastric pain, which is made worse by lying flat.
Vomiting and weight loss (rare)
Bleeding and/or anaemia (secondary to oesophageal ulceration)
Hiccups or palpitations
What does gastric outflow obstruction result in?
Early satiety (fullness)
Vomiting
Nutritional failure
What investigations for hiatus hernia?
Upper GI endoscopy - OGD = gold standard
Shows upward displacement of the gstro-oesophageal junction
What is the advice/management for a hiatus hernia?
Conservative: Weight loss Low fat, earlier meals, smaller portion diet Sleep with more pillows Smoking cessation Reduce alcohol intake
Medical
PPI
Surgical
Cruroplasty - hernia is reduced from the thorax into the abdomen and the hiatus reapproximated to the appropriate size
Fundoplication - gastric fundus is wrapped around the lower oesophagus and stitched in place - aims to strengthen the LOS helping prevent reflex and keep the GOJ in place
What should PPis be taken
In the morning before food otherwise the drugs binding sites becomes internalised and are ineffective
What are the indications for surgical management?
Remaining symptomatic despite maximal medical therapy
Increased risk fo strangulation/volvulus - rolling type or mixed or other abdominal viscera
Nutritional failure due to gastric outlet obstruction
What should you do for a patient who may be obstructed, strangulated or volvulus before surgery?
Decompress the stomach via NG tube
What are complications of surgery?
Recurrence of hernia
Abdominal bloating - cannot belch, secondary to improved anti-reflux mechanism
Dysphagia - if fundoplication is too tight - common early after surgery due to oedema
Fundal necrosis if the blood supply via left a gastric artery has been displaced
What are complications of hiatus hernia?
Rolling type - incarceration and strangulation
Gastric volvulus - stomach twists on itself by 180, leading to obstruction of the gastric passage and tissue necrosis.
