Hiatus Hernia

Question 1

Define Hiatus Hernia

Answer 1

Protrusion of the intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm.

Question 2

What are the types of Hiatus Hernia

Answer 2

Type 1: sliding (most common)
Type 2: para-oesophageal hernia/rolling hernia
Type 3: Mixed sliding + rolling
Type 4: Giant hernia, stomach + 1 more structure

Question 3

Aetiology of Hiatus Hernia

Answer 3

Clear aetiology unknown
Normal swallowing - oesophagus shortens several cm secondary to muscular contraction
This action + coughing, sneezing, straining, strenuous exercise (increases intra-abdominal pressure) -> movement of rate distal oesophagus through the oesophageal hiatus and into posterior mediastinum

Question 4

Risk factors for Hiatus Hernia

Answer 4

Obesity 
Previous gastro-oesophageal procedure 
Elevated intra-abdominal pressure
Male 
Structural abnormalities of the oesophageal hiatus 
Incisions, umbilical or inguinal hernia
Disorder of collagen metabolism 
Advanced age

Question 5

Symptoms of Hiatus Hernia

Answer 5

Heartburn
Regurgitation
Chest pain 
Dysphagia 
Odynophagia 
Haematemesis 
SOB, cough, wheeze
Vomiting 
Fever and chills
Confusion

Question 6

Signs of Hiatus Hernia on examination

Answer 6

Bowel sounds in chest

Question 7

Investigations for Hiatus Hernia

Answer 7

Upper GI barium meals/swallows are the most definitive modality in diagnosing hiatus hernia

Upper GI series (X rays + contrast): stomach is partially or completely intrathoracic
CXR: retrocardiac air bubble or normal
OGD: inflammation of oesophagus + proximal migration of the gastro-oesophageal junction
CT/MRI: partial or complete intrathoracic stomach + herniation of other organs in the chest

Manometry: double hump configuration

Question 8

Management for acute presentation of Hiatus Hernia

Answer 8

1. PPI e.g. omeprazole

2. Lifestyle modification:
Lose weight
Elevate head of bed
Avoid large meals and before bedtime
Alcohol and acidic food avoidance
Avoid nicotine, chocolate, peppermint, caffeine, fatty foots 
Avoid nitrates, CCBs and beta blockers

Question 9

Management for ongoing Hiatus Hernia

Answer 9

Surgical repair ± Anti-reflux procedure e.g. fundoplication (Nissen)

Irreversible organ ischaemia and/or necrosis: gastric resection

Question 10

Complications of Hiatus Hernia

Answer 10

Gastric volvulus
Obstruction
Diarrhoea
Barrett’s oesophagus

Post-op:
Bloating
Hernia
Dysphagia
Haemorrhage 
Mesh infection

Question 11

Prognosis for Hiatus Hernia

Answer 11

No cure for sliding hiatus hernia, but adequate symptom relief
Long term cure if successful surgical repair