Hiatus hernias Flashcards
What is a hiatus hernia?
Hiatal hernia = protrusion of the intra-abdominal contents through the diaphragm into the thoracic cavity via an enlarged oesophageal hiatus
What is the aetiology of hiatus hernias?
Normal physiology
Oesophagus shortens several centimetres with swallowing due to contraction of the longitudinal muscle layer
Increased intra-abdominal pressure (sneezing, coughing, exercise) produce movement of the distal oesophagus through the hiatus
Phreno-oesophageal ligaments create resistance to counteract the movement by their stretch and recoil
Disruption of normal physiology
Muscle weakness and loss of elasticity
Increased intra-abdominal pressure
Fibrosis of longitudinal muscles (e.g. chronic oesophagitis)
What are the risk factors of hernia?
Obesity
Previous gastro-oesophageal procedure
Increased intra-abdominal pressure - Pregnancy, ascites, constipation
Male
Structural abnormalities
Other hernias
Collagen metabolism disorder
Old age
What is the epidemiology of hiatus hernias?
Difficult to determine prevalence due to many being asymptomatic and varying diagnostic criteria
Could be up to 50% in Western
Lower prevalence in Eastern populations
Incidence of symptomatic cases closely related to GORD diagnosis
What are the different types of hiatus hernia?
Type 1 = sliding - Protrusion of GOJ followed by body of stomach through oesophageal hiatus
Most common – 90-95% of cases -> heartburn, GORD, dysphagia
Type 2 = rolling - Protrusion of fundus/body of stomach through oesophageal hiatus with the GOJ still below the diaphragm -> chest pain, epigastric pain, heart burn, fullness, nausea
Type 3 = mixed - Protrusion of fundus/body of stomach through into the chest, Protrusion of GOJ into the chest – but resting below the herniated stomach
Type 4 = giant - Protrusion of stomach and other organs (colon, small bowel, omentum, spleen)
What are the symptoms of hiatus hernia?
Asymptomatic Heart burn/chest pain Regurgitation +/- non-bilious vomiting +/- haematemesis Epigastric pain Dysphagia +/- odynophagia SOB Cough Fullness Nausea
What are the signs of hiatus hernia?
Bowel sounds in chest
Obesity
Wheezing
What are the investigations for hiatus hernia?
CXR - Retro-cardiac air bubble
Upper GI series (X-ray with liquid suspension) -Partial/complete intra-thoracic stomach
Other investigations
Barium swallow - DIAGNOSTIC
OGD - Oesophageal inflammation, Proximal OGJ migration
CT - Partial/complete intra-thoracic stomach
Oesophageal manometry and pH monitoring - Double-hump configuration, Abnormal 24hr pH
What is the management of hiatus hernia?
Acute
Upper GI haemorrhage/obstruction/volvulus - Resuscitation and urgent surgical repair
Irreversible organ ischaemia/necrosis - Surgical resection and supportive care
Symptomatic GORD - PPIs, Lifestyle changes
Ongoing
Asymptomatic - No intervention required
GORD - PPIs
Type 1 refractory to medical therapy - Surgical repair +/- anti-reflux (usually indicated as dissection typically destroys all LOS tissue physiology)
Types 2/3/4 - Surgical repair +/- anti-reflux, Long term risk of strangulation, volvulus, mediastinitis
What are the complications of hiatus hernia?
Untreated Gastric volvulus - Rare but potentially deadly in type 2/3 hernias Obstruction Incarceration + ischaemia + necrosis GI bleeding GORD -> Barrett’s oesophagus
Following surgery Bloating - Common complaint in first several months after an anti-reflux procedure Early/late recurrent hernia Dysphagia Haemorrhage Fundal necrosis Diarrhoea Early mesh infection
What is the prognosis of hiatus hernia?
Most have adequate relief of symptoms with medical therapy
Excellent LT outcome after surgery in 90% of cases
Paraoesophageal hernias generally enlarge with time, meaning the risk of incarceration is 5%
