Hiatus hernia (GI)

Question 1

Define hiatus hernia.

Answer 1

Protrusion of intra-abdominal contents (usually the stomach) into the thoracic cavity through an enlarged oesophageal hiatus of the diaphragm

Question 2

Describe the pathophysiology of hiatus hernias.

Answer 2

• normally, increased intra-abdominal pressures in coughing, sneezing, straining and strenuous exercise raise distal oesophagus and gastro-oesophageal junction through the oesophageal hiatus and into the posterior mediastinum
• this movement is resisted by the phreno-oesophageal ligaments (between diaphragm an GOJ)
• physiological movement and stretching may enlarge the hiatus –> permanent portion of stomach above diaphragm

Question 3

What are the two types of hiatus hernia?

Answer 3

• sliding hiatus hernia (most common - 95%) - displacement of GOJ above diaphragm, decreasing LOS pressure –> predisposes to GORD
• rolling hiatus hernia - GOJ remains below diaphragm but a separate part of stomach e.g. fundus herniates through oesophageal hiatus

Question 4

What is a sliding hiatus hernia?

Answer 4

Displacement of gastro-oesophageal junction above the diaphragm

Decreases LOS pressure –> predisposes to GORD

Question 5

What is a rolling hiatus hernia?

Answer 5

Gastro-oesophageal junction remains below diaphragm, but a separate part of stomach e.g. fundus herniates through the oesophageal hiatus

Stomach herniation such that there is rotating/twisting of the stomach as it migrates into the chest –> intermittent strangulation with obstruction and ischaemia

Question 6

Which type of hiatus hernia needs more urgent treatment and why?

Answer 6

Rolling hiatus hernia as it can lead to volvulus - strangulation with obstruction and ischaemia –> necrosis

Question 7

What can rolling hiatus hernia lead to? (2)

Answer 7

• ischaemic ulcers can form –> GI haemorrhage with haematemesis
• ischaemic necrosis –> mediastinitis + death

Question 8

What are the subtypes of hiatus hernia?

Answer 8

• hiatus hernia most commonly contains a variable portion of the stomach (type I, II or III)
• less commonly it may contain the transverse colon, omentum, small bowel, or spleen (type IV)
• sliding type I hiatus hernias are generally differentiated from the remaining three types, which are collectively referred to as para-oesophageal hernias

Question 9

What are the clinical features of hiatus hernia? (11)

Answer 9

• heartburn (sliding HH associated with GORD)
• regurgitation (sour/metallic taste, worse on lying)
• dysphagia
• odynophagia
• SOB (compromised lung expansion as space occupied by HH)
• chronic cough and wheeze
• chest pain (complicated HH)
• haematemesis (complicated rolling HH)
• non-bilious vomiting (complicated rolling HH)
• fever and chills (complicated HH)
• confusion (complicated HH)

Question 10

How might hiatus hernia present?

Answer 10

Asymptomatic

Question 11

What might be found on examination of hiatus hernia?

Answer 11

Bowel sounds in chest

Question 12

What are some risk factors for hiatus hernia? (7)

Answer 12

• obesity
• GORD
• increased intra-abdominal pressure (pregnancy, ascites, chronic cough, constipation)
• previous gastro-oesophageal procedure
• incisional, umbilical or inguinal hernia
• increased age
• male sex

Question 13

What are the first-line investigations for hiatus hernia? (2)

Answer 13

• upper GI fluoroscopy with oral contrast
• CXR

Question 14

What is an upper GI series and what does it show in hiatus hernia?

Answer 14

• group of X-rays including upper GI fluoroscopy with oral contrast
• stomach is partially or completely intrathoracic

Question 15

What is the most sensitive investigation for hiatus hernia?

Answer 15

Barium swallow - assesses type and size of hernia

Question 16

What might be seen on CXR in hiatus hernia?

Answer 16

Retrocardiac air bubble (or normal)

Question 17

What investigation might be done first for hiatus hernia, based on symptoms?

Answer 17

Upper GI endoscopy (due to GORD-like symptoms) - hiatus hernia may be found incidentally

Question 18

What are some differential diagnoses for hiatus hernia? (6)

Answer 18

• GORD
• angina pectoris (exertional chest pain)
• pneumonia
• gastric outlet obstruction
• oesophageal motility disorder
• gastric atonia

Question 19

How do we manage uncomplicated sliding hiatus hernia?

Answer 19

Symptomatically + conservative: weight loss and PPIs (4-8 weeks)

Question 20

When is surgery done for hiatus hernia? (3)

Answer 20

• rolling hiatus hernia (prophylactically even if asymptomatic, as may strangulate)
• sliding hiatus hernia if Sx persist despite conservative Rx
• if complicated with upper GI haemorrhage, obstruction, volvulus

Question 21

How is surgery done for hiatus hernia?

Answer 21

Nissen Fundoplication + hiatoplasty

• stomach pulled down through oesophageal hiatus and part of the stomach is wrapped (360 degrees) around the oesophagus to make a new sphincter and reduce likelihood of herniation - offered to medication resistant patients
• (Belsey Mark IV Fundoplication - 270 degree wrap)
• (Hill Repair - gastric cardia anchored to posterior abdominal wall)

Question 22

How do we manage irreversible ischaemia +/- necrosis in hiatus hernia?

Answer 22

Gastric resection

Question 23

How do we manage symptomatic GORD?

Answer 23

PPI + lifestyle changes (weight loss)

Question 24

What are the complications of hiatus hernia? (4)

Answer 24

• sliding hiatus hernia complications - come from GORD e.g. oesophagitis, Barrett’s, oesophageal strictures
• upper GI bleeding
• gastric ulcers
• gastric volvulus (strangulation, necrosis)

Question 25

Describe the prognosis of uncomplicated sliding hiatus hernia.

Answer 25

Adequate symptom relief with medical therapy, but not cured

Question 26

What does successful hiatus hernia repair with anti-reflux procedure result in?

Answer 26

Long-term cure for hiatus hernia and GORD, but is a major procedure