Hiatus hernia

Question 1

Define

Answer 1

Prolapse of the upper stomach through the diaphragmatic oesophageal hiatus

(Rarely, a large defect can allows spleen/pancreas through)

• Sliding (80%) – where the gastro-oesophageal junction slides up into the chest, acid reflux is common (as lower oesophageal sphincter becomes less competent)
• Rolling (20%) – gastro-oesophageal junction remains in the abdomen but a bulge of stomach herniates up into the chest, alongside the oesophagus

(Acid reflux is uncommon as G-O junction remains intact

Question 2

Causes

Answer 2

1) Widening of the diaphragmatic hiatus
(2) Pulling up of the stomach (due to oesophageal shortening)
(3) Pushing up of the stomach (due to ↑intra-abdominal pressures)

Question 3

Risk factors

Answer 3

Incidence increases with:

1. Woman
2. Obesity
3. Pregnancy
4. Ascites
5. Genetic predisposition
6. Shortening of the oesophagus (e.g. chronic oesophagitis)

Question 4

Epidemiology

Answer 4

• Common in WESTERN countries
• Increased frequency with age
• 70% of patients are > 70 yrs
• Women and obesity

Question 5

Symptoms

Answer 5

Most are ASYMPTOMATIC

Sliding hernias are more likely to cause symptoms

Patients may present with symptoms of GORD

• Heartburn
• Waterbrash
• Flatulence
• Difficulty in swallowing (rarely)

Question 6

Signs

Answer 6

Usually NO SIGNS

Question 7

Investigations

Answer 7

Bloods

• FBC - check for iron deficiency anaemia

Radiology

• CXR - gastric air bubble may be seen above the diaphragm
• Barium swallow

Endoscopy

Question 8

Management

Answer 8

Medical

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

Surgical

• Necessary in a MINORITY of patients
• Usually performed in patients with complications of reflux disease despite aggressive medical treatment or pulmonary complications (e.g. aspiration pneumonia)
• Nissen Fundoplication
• The stomach is pulled down through the oesophageal hiatus and part of the stomach is wrapped (360 degrees) around the oesophagus to make a new sphincter and reduce the likelihood of herniation

Belsey Mark IV Fundoplication

• 270 degree wrap

Hill Repair

• Gastric cardia is anchored to the posterior abdominal wall

Question 9

Complications

Answer 9

Oesophageal

Intermittent bleeding

Oesophagitis

Erosions

Barrett’s oesophagus

Oesophageal strictures

Non-Oesophageal

Incarceration of hiatus hernia (only with paraoesophageal hernias)

This can lead to strangulation and perforation

Question 10

Prognosis

Answer 10

Generally GOOD

Sliding hernias have a better prognosis than rolling hernias