Hiatus Hernia Flashcards
Define hiatus hernia.
Hiatus hernia is the protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm, usually containing a variable portion of the stomach.
Less commonly, it may contain transverse colon, omentum, small bowel, or spleen, or some combination of these organs.
All herniated contents are usually contained within a sac of peritoneum.
Which type of hernia is most common?
Sliding - type I
Accounts for 90-95% of all cases
How common are sliding hiatus hernias?
Present in 30% of people over 50 years
Describe a sliding hiatus hernia.
The oesophageal–gastric junction and part of the stomach ‘slide’ through the hiatus so that it lies above the diaphragm.
What is a rolling or para-oesophageal hernia?
- Part of the fundus of the stomach prolapses through the hiatus alongside the oesophagus.
- The lower oesophageal sphincter remains below the diaphragm and remains competent
What is the aetiology of hiatus hernias?
Unknown
But oesophagus shortens during swallowing secondary to contraction of its longitudinal muscle layer. This in combination with elevations in IAP e.g. coughing, straining, exercise can move distal oesophagus through the oesophageal hiatus into posterior mediastinum.
What is the pathophysiology of a hiatus hernia?
Displacement of the gastro-oesophageal junction above diaphragm decreases LOS pressure so the damaged anti-reflux mechanism predisposes to GORD. This is the most common symptom of a sliding hiatus hernia.
In the relatively uncommon (~20%) paraoesophageal hiatus hernias , rotation and migration of the stomach into the chest can produce intermittent strangulatiuon and obstruction and ischaemia. This leads to pain, vomiting, ulcers and necrosis.
How are hiatus hernias classified?
- Type I- sliding hiatus hernia
- Type II - pure paraoesophageal/rolling hernia
- Type III - mixed type I and II - fundus or body of stomach have herniated into chest and the gastro-oesophageal junction has also herniated into chest but rests below the herniated stomach
- Type IV - giant hiatus hernia or occurrence of any type of hernia with herniation of one of more other organs such as colon, small bowel, omentum and spleen.
What are the risk factors for developing a hiatus hernia?
- Obesity
Other:
- Previous gastro-oesophageal procedure
- Elevated IAP
- Male sex
- Abnormalities of the oesophageal hiatus or the phreno-oesophageal ligaments - weakness/malformations but there is no prototypical anatomical variant that predisposes to it
- Incisional, umbilical or inguinal hernia
- Disorder of collagen metabolism - lacks supportive data
- Old age
What is a typical presentation of hiatus hernias?
- Heartburn
- Regurgitation
- Obesity
Other:
- Chest pain
- Dysphagia
- Odynophagia
- Haematemesis (if more than 55cc may represent a complicated hiatus hernia)
- SOB
- Cough
- Otropharyngitis
- Non-bilious vomiting
Which type of hernia presents with no symptoms?
Sliding hiatus hernia
Produces no symptoms – any symptoms are due to reflux
What are the signs of hiatus hernia on examination?
- Oropharyngitis (secondary to reflux of gastric contents)
- Wheezing (secondary to aspiration of refluxate)
- Decreased left chest breath sounds
- Dullness to thoracic percussion
- Presence of bowel sounds in the left chest.
If complicated:
- Pyrexia
- Tachycardia
- Hypotension
- Tachypnoea
- Altered mental status
- Some or all of the signs elicited with uncomplicated hiatus hernia
What investigations would you do for a hiatus hernia?
- CXR - retrocardiac air bubble or normal
- Contrast UGI series
- OGD - checks for oesophagitis but can be misleading
- CT or MRI - helps determine whether other organs have migrated up
- Oesophageal manometry and pH monitoring - for monitoring in patients with atypical symptoms. Double hump pattern on manometry and abnormal pH results only with larger hiatus hernias.
What is the management of hiatus hernias?
Type I refractory to medical therapy or patient prefers surgery → surgical repair +/- anti-reflux procedure
Types II, III, IV - surgical repair with or without anti-reflux procedure
GORD - lifestyle modifications, PPI
UGI haemorrhage +/- obstruction +/- volvulus - resuscitation and urgent surgical repair
Irreversible organ ischaemia +/- necrosis - surgical resection and supportive care
When does a rolling hiatus hernia produce pain?
Occasionally, severe pain occurs due to volvulus or strangulation
