hiatus hernias

Question 1

definition of hiatus hernia

Answer 1

prolapse of the upper stomach through the diaphragmatic oesophageal hiatus

sliding (80%) - gastrooesophageal junction slides into chest, acid reflux happens as lower oesophageal sphincter becomes less competent

paraoesophageal hernia (rolling) - gastroosophageal junction remains in abdo, bulge of stomach herniates into chest alongside oesophagus. GORD less common as gastro-oesophageal junction is intact

Question 2

aetiology of hiatus hernia

Answer 2

congenital, traumatic or non-traumatic

non-traumatic divided into sliding, rolling or mixed

RF

• obesity
• low fibre diet
• chronic oesophagitis
• abdominal ascites
• pregnancy

Question 3

epidemiology of hiatus hernia

Answer 3

common in west

increased frequency with age - from 10% in patientsyounger than 40 years to 70% in patients older than 70 years.

Question 4

sx of hiatus hernioa

Answer 4

majority asymptomatic

sliding > symptoms

GORD - heartburn, acid dyspepsia and its complications

no correlation between size of hernia and symptoms

Question 5

signs of hiatus hernioa

Answer 5

N/a - unless complications

Question 6

ix for hiatus hernia

Answer 6

bloods - FBC for IDA

radiology

• CXR (large hernias appear as a gastric air bubble behind the heart)
• barium swallow or meal - visualisation and distiguish the types

endoscopy

• diagnosis of condition and complications - eg erosive oesophagitis, ulcer in hernia, barrett’s oesophagus or tumour
• biopsy of abnormal or suspicious areas

Question 7

med mx of hiatus hernia

Answer 7

lifestyle - weight loss

inhibit acid production - H2 antagonists, PPis

enhance upper GI motility

Question 8

surgical mx of hiatus herni

Answer 8

necessary only in minority of patients

indications include complications of reflux despite aggressive treatment, those with pulmonarycomplications (e.g. asthma, recurrent aspiration pneumonia)

open or laproscopically

nissen fundoplication

• formation of a 360 fundic wrap around the gastrooesophageal junction
• diaphragmatic hiatus is repaired
• A variant of the Nissen wrap and involves a 1808wrap in an attempt to reduced the likelihood of post-op dysphagia.

belsey Mark IV fundoplication

• 270degress wrap
• L and R crura of the diaphragm are approximated

hill repair

• cardia of the stomach is anchored to posterior abdo areas eg medial arcuate ligament
• augments the angle of His and strengthens the antireflux mechanism

Question 9

prophylactic repair of hiatus hernia

Answer 9

Although paraoesophageal hernias may strangulate the risk of this drops dramatically after 65yrs. Prophylactic repair is only undertaken in those considered at high risk, due to operative mortality (≈1–2%).

Question 10

complications of hiatus hernia

Answer 10

oesophageal complications

• responsible for intermittent bleeding from oesophagitis, erosions, discrete oesophageal ulcer
• could lead to anaemia, barrett’s oesophagus or strictures

nonoesophageal complications

• Incarceration of a hiatal hernia is rare and occurs only with para-oesophageal hernia
• enlarge with time - sometimes whole stomach in chest
• The risk of incarcer-ation, leading to strangulation or perforation, is approx 5% - Because of the high mortality associated with strangulation, elective repair is advised for para-oesophageal hernias.

Question 11

Px of hiatus hernia

Answer 11

Generally good with most not causing severe problems (sliding hernias have abetter prognosis than rolling hernias).