Hiatus hernia

Question 1

Define:

Answer 1

Prolapse of the upper stomach through the diaphragmatic oesophageal hiatus.

Question 2

Aetiology:

Answer 2

Traumatic
Congenital
Non-traumatic:
-Sliding (80%) - the hernia moves in and out of the chest. There is acid reflux as lower oesophageal sphincter loses competency.
-Paraoesophageal (rolling - 20%) - hernia goes through the hole of the diaphragm next to the oesophagus. No acid reflux
-Mixed

Question 3

Risk factors:

Answer 3

Obesity 
Low fibre diet
Pregnancy 
Chronic oesophagitis 
Ascites

Question 4

Epidemiology:

Answer 4

Common in the western world

Increased frequency with age

70% of cases are in the over 70’s.

More common in older obese women

50% symptomatic of GORD

Question 5

Symptoms:

Answer 5

usually asymptomatic

Symptoms of GORD + painless regurgitation = Hiatus hernia

Symptoms of GORD:

• waterbrash
• heart burn

No correlation between size and severity

Question 6

Signs:

Answer 6

No signs

Question 7

Investigations:

Answer 7

Bloods - FBC (look for iron deficiency anaemia)

CXR (first line) –> gastric bubble may be above the diaphragm
Barium swallow

Endoscopy - this is to identify oesophagitis but can be used to exclude a hiatus hernia

Question 8

Management:

Answer 8

Medical:

• Modify lifestyle factors (lose weight)
• Inhibit acid production (PPIs)
• Enhance upper GI motility

Surgical

• Only in a minority in patients who may show complications of acid reflux
• May be done prophylactically for rolling hiatus hernias are there is a risk of strangulation.
• Nissen fundoplication (stomach is pulled down through the oesophageal hiatus+ part of the stomach is wrapped (360 degrees) around the oesophagus to make a new sphincter
• Hill repair (Gastric cardia is anchored to the posterior abdominal wall)
• Belsey Mark IV fundoplication (270 degree wrap)

Question 9

Complications:

Answer 9

Oseophageal:

• Barrett’s
• erosions
• strictures
• oesophagitis
• intermittent bleeding

Non-oesophageal
-rolling can strangulate and perforate

Question 10

Prognosis:

Answer 10

usually have a good prognosis

Rolling have a worse prognosis than sliding