Hiatus Hernias

Question 1

Definition

Answer 1

Prolapse of the upper stomach through the diaphragmatic oesophageal hiatus

Question 2

Aetiology

Answer 2

• Congenital
• Traumatic

• Non-traumatic
o Sliding - the hernia moves in and out of the chest
o Paraoesophageal (rolling) - the hernia goes through a whole in the diaphragm
next to the oesophagus
o Mixed

Question 3

Risk factors

Answer 3

o Obesity
o Low-fibre diet
o Chronic oesophagitis
o Ascites
o Pregnancy

Question 4

Epidemiology

Answer 4

• Common in WESTERN countries
• Increased frequency with age
• 70% of patients are > 70 yrs

Question 5

Presenting symptoms

Answer 5

• Most are ASYMPTOMATIC
• Sliding hernias are more likely to cause symptoms

• Patients may present with symptoms of GORD
o Heartburn
o Waterbrash

• NO correlation between the size of the hernia and severity of the symptoms

Question 6

Signs on physical examination

Answer 6

Usually NO SIGNS

Question 7

Investigations

Answer 7

• Bloods
o FBC - check for iron deficiency anaemia

• Radiology
o CXR - gastric air bubble may be seen above the diaphragm
o Barium swallow

• Endoscopy

Question 8

Management plan (medical)

Answer 8

o Modify lifestyle factors (e.g. lose weight)
o Inhibit acid production (e.g. PPIs)
o Enhance upper GI motility

Question 9

Management plan (surgical)

Answer 9

o Necessary in a MINORITY of patients
o Usually performed in patients with complications of reflux disease despite
aggressive medical treatment or pulmonary complications (e.g. aspiration
pneumonia)

o Nissen Fundoplication
• The stomach is pulled down through the oesophageal hiatus and part of the
stomach is wrapped (360 degrees) around the oesophagus to make a new
sphincter and reduce the likelihood of herniation

o Belsey Mark IV Fundoplication
• 270 degree wrap

o Hill Repair
• Gastric cardia is anchored to the posterior abdominal wall

Question 10

Possible complications

Answer 10

• Oesophageal
o Intermittent bleeding 
o Oesophagitis
o Erosions
o Barrett's oesophagus
o Oesophageal strictures

• Non-Oesophageal
o Incarceration of hiatus hernia (only with paraoesophageal hernias)
o This can lead to strangulation and perforation

Question 11

Prognosis

Answer 11

• Generally GOOD

* Sliding hernias have a better prognosis than rolling hernias