Hiatus Hernia - Upper GI Flashcards
What is a hiatus hernia?
- protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm.
- A hiatus hernia most commonly contains
- a variable portion of the stomach;
- less commonly, it may contain transverse colon, omentum, small bowel, or spleen, or some combination of these organs.
- The herniated contents are usually contained within a sac of peritoneum.
What are the different classifications of hiatus hernias?
Types I - IV
What is the aetiology of a hiatus hernia?
A clear aetiology for hiatus hernia is not known.
- During normal swallowing, the oesophagus shortens several centimetres secondary to contraction of its longitudinal muscular layer.
- This action, in combination with elevations in intra-abdominal pressure such as from coughing, sneezing, straining, and strenuous exercise, produces physiological movement of the distal oesophagus and possibly the gastro-oesophageal junction through the oesophageal hiatus and into the posterior mediastinum.
- This movement is countered by the resistance of the phreno-oesophageal ligaments, which run between the diaphragm and the gastro-oesophageal junction.
- These ligaments are somewhat elastic in terms of their stretch and recoil.
- At some point, however, the physiolgical movement and stretching may enlarge the hiatus, leading to permanent residence of a portion of the stomach above the diaphragm.
- Although a number of risk factors predispose a patient to hiatus hernia, the precise cause of hiatus hernia is difficult to know with certainty in most patients.
Name the risk factors for hiatus hernia
- obesity
- male > female
- advanced age
- structural abnormalities of the oesophageal hiatus or the phreno-oesophageal ligaments
- elevated intra-abdominal pressure
- Hx of previous gastro-oesophageal procedure
- Hx of incisional, umbilical, or inguinal hernia
- disorder of collagen metabolism
Summarise the epidemiology of hiatus hernias
- The prevalence of hiatus hernia can only be estimated, because most of these hernias cause mild or no symptoms and diagnostic criteria may vary.
- Clinical estimates of the prevalence of hiatus hernia in western populations range up to 50%.
- The prevalence may be lower in eastern populations
- sliding (type I) hernia = most common = 90% to 95% of cases
What are the presenting symptoms of a hiatus hernia?
- asymptomatic
GI symptoms:
- heartburn
-
dysphagia
- difficulty swallowing
-
odynophagia
- pain when swallowing
- haematemesis
-
non-billious vomiting
- feature of a complicated hiatus hernia
resp symptoms:
- SOB
- chest pain
-
wheezing
- A result of bronchospasm, which is secondary to aspiration.
- hoarseness
- painful throat
- cough
- asthma
misc. symptoms:
- anaemia
-
Fever and chills
- feature of a complicated hiatus hernia
-
confusion
- feature of a complicated hiatus hernia
Is there a correlation between the size of the hiatus hernia & severity of symptoms?
NO correlation between the size of the hernia and severity of the symptoms
What does a complicated hiatus hernia involve?
- obstruction
- bleeding
- and/or ischaemia
What are the signs of a hiatus hernia O/E?
- Usually NO SIGNS
- ~ bowel sounds in chest O/A
What are the primary investigations for ?hiatus hernia?
-
CXR
- will show retrocardiac air bubble or normal
-
Contrasted upper gastrointestinal series
- (also known as an upper GI or as a barium oesophagram)
- for pts with moderate to severe symptoms
- stomach is partially or completely intrathoracic
What would a retrocardial air bubble signify on CXR w.r.t. to a hiatus hernia?
retrocardiac hiatus hernia (stomach contents pushes behind heart)
- characterized by the presence of a stomach bubble with an air fluid level that is visible on top of the diaphragm.
Name some possible secondary investigations for a ?hiatus hernia?
-
oesophago-gastro-duodenoscopy (ODG)
- for moderate to severe symptoms
- check for the presence of oesophagitis or oesophageal dysplasia
- findings are helpful in directing therapy
- will show inflammation of the oesophagus & proximal migration of the gastro-oesophageal junction
-
CT or MRI
- only when diagnosis is not clear or other pathology is suspected
- may show partial or complete intrathoracic stomach and herniation of other intra-abdominal organs into the chest (retrocardiac hiatus hernia)
-
oesophageal manometry and pH monitoring
- Done in patients in whom additional confirmation of the diagnosis is required
- shows double hump configuration due to gastric herniation above the high-pressure zone of the crura
- Abnormal 24-hour pH monitoring is seen in patients with larger hiatus hernias.
Explain the management plan for a hiatus hernia
Tx depends on:
- the patient’s symptoms
- anatomical configuration of the hernia.
main goal of treatment for hiatus hernia is to alleviate the patient’s symptoms
1st lifestyle changes
- losing weight
- elevating the head of the bed
- avoiding large meals
- avoiding meals just before bedtime
- avoiding alcohol and acidic foods.
- Substances suspected to inhibit the lower oesophageal sphincter should also be avoided
- nicotine
- chocolate
- peppermint
- caffeine
- fatty foods
- medications such as calcium-channel blockers, nitrates, and beta-blockers
2nd medical therapy
- if symptoms of GORD are present, Tx = medically with a PPI
3rd surgical correction - only needed in a minority of patients
- laproscopic hernia repair
- laproscopic cruroplasty
- Nissen Fundoplication
What are the principles/steps of laproscopic hernia repair surgery?
- reduction of hernia contents
- excision of the hernia sac
- lengthening of the intra-abdominal oesophagus
- primary cruroplasty with or without mesh reinforcement
- anti-reflux procedure / gastropexy
gastropexy = surgical fixation of the stomach
Which minority of patients require surgical correction of their hiatus hernia?
-
complications of reflux disease
- despite aggressive medical treatment OR
-
pulmonary complications
- (e.g. aspiration pneumonia)
-
URGENTLY: life-threatening complications of
- obstruction
- volvulus
- upper gastrointestinal haemorrhage
- irreversible ischaemia or necrosis of the stomach or other herniated organs, such as small intestine or colon
