Hiatus Hernia Flashcards
Definition of 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?
Protrustion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus.
Typically the stomach herniating.
It can also be small bowel, colon or mesentery but these are rare
Epidemiology
Extremely common but asymptomatic
Around a third of individuals over the age of 50 are believed to have a hiatus hernia
Subtypes
Sliding hiatus hernia (80%)
Rolling or para-oesophageal hernia (20%)
Explain sliding hiatus hernia
GOJ, the abdominal part of the oesophagus and frequently the cardia of the stomach move or slides upwards through the diaphragmatic hiatus into the thorax.
Explain rolloing or para-oesophageal hernia.
Upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ.
It creates a “bubble” of stomach in the thorax and is a true hernia with a peritoneal sac.
Mixed type can also occur.
Risk factors
Age is the biggest risk factor due to…
Age-related loss of diaphragmatic tone
Increasing intrabdominal pressures
Increased size of diaphragmatic hiatus
Pregnancy
Obesity
Ascites
Clinical features
Usually asymptomatic
Might have GORD symptoms like burning epigastric pain made worse by lying flat.
Vomiting and weight loss, bleeding +/- anaemia
Hiccups or palpitations (irritates the pericardial sac)
Dysphagia
Examination findings
Typically normal
If the hernia is large enough bowel sounds may be ausculated in the chest
Sometimes gastric outflow can become blocked leading to early satiety, vomiting and nutritional failure.
What needs to be done?
Transfer to nearested oesophago-gastric unit
Dx
Cardiac chest pain
Gastric or pancreatic cancer
GORD
Investigations
Oesophagogastroduodenoscopy (OGD) is gold standard
Can also be diagnosed incidentaly on CT or MRI scan
Contrast swallow might be done but is not commonly used.
OGD findings of hiatus hernia
Upward displacement of GOJ aka Z-line
Conservative management
PPis like omeprazole
Should be taken in the morning before food.
Weight loss and alteration of diet
Smoking cessation and reduction in alcohol intake (both nicotine and alcohol are thought to inhibit the LOS)
Indications of surgical intervention
Remaining symptomatic despite maximal medical therapy
Increased risk of strangulation/volvulus
Nutritional failure
What should be done prior to surgical management in suspected obstruction, strangulation or stomach volvulus?
Stomach decompression via NG tube
Types of hiatus hernia surgery
Cruroplasty
Fundoplication
Explain cruroplasty
Hernia reduced from thorax into abdomen and hiatus is reapproximated to the appropraite size
Any large defects usually require mesh to strengthen the repair.
Explain fundoplication
Gastric fundus is wrapped around the LOS and stitched in place.
This aims to strengthen the LOS to help prevent reflux and keep GOJ in place below the diaphragm.
Complications of hiatus hernia surgery
Recurrence of the hernia
Abdominal bloating (inability to belch)
Dysphagia if fundoplication is too tight or if crural repair is too narrow - patient may need revisional surgery
Fundal necrosis (blood supply via left gastric artery and short gastric vessels are disrupted (this is a surgical emergency requiring major gastric resection))
Complications of hiatus hernia
Incarceration and strangulation
Gastric volvulus leading to obstruction of gastric passage and tissue necrosis
Borchardt’s traid of gastric volvulus
Severe epigastric pain
Retching without vomiting
Inability to pass an NG tube
