Hiatus Hernias

Question 1

Define Hiatus Hernia?

Answer 1

Prolapse of the upper stomach through the diaphragmatic oesophageal hiatus

Question 2

What is the aetiology of Hiatus Hernias?

Answer 2

Congenital
Traumatic
Non-traumatic

Question 3

What are the non-traumatic aetiology of Hiatus Hernias?

Answer 3

Sliding - the hernia moves in and out of the chest
Paraoeseophageal (rolling) - the hernia goes through a hole in the diaphragm next to the oesophagus
Mixed

Question 4

What are the risk factors for Hiatus Hernias?

Answer 4

Obesity 
Low-fibre diet 
Chronic oesophagitis 
Ascites 
Pregnancy

Question 5

What is the epidemiology of Hiatus Hernias?

Answer 5

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

Question 6

What are the presenting symptoms of Hiatus Hernias?

Answer 6

Most are asymptomatic
Sliding hernias are more likely to cause symptoms
Symptoms of GORD
No correlation between the size of the hernia and severity of the symptoms

Question 7

What are the symptoms of GORD in Hiatus Hernias?

Answer 7

Heartburn

Waterbrash

Question 8

What are the signs of Hiatus Hernias on physical examination?

Answer 8

Usually NO SIGNS

Question 9

What investigations do you do for Hiatus Hernias?

Answer 9

Bloods
Radiology
Endoscopy

Question 10

What bloods do you do for Hiatus Hernias?

Answer 10

FBC - check for iron deficiency anaemia

Question 11

What radiology do you do for Hiatus Hernias?

Answer 11

CXR - gastric air bubble may be seen above the diaphragm

Barium swallow

Question 12

What are the management plans for Hiatus Hernias?

Answer 12

Medical Management plan
Surgical Management plan
Belsey Mark IV Fundoplication
Hill Repair

Question 13

What is the Medical Management Plan for Hiatus Hernias?

Answer 13

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

Question 14

What is the surgical management plan for Hiatus Hernias?

Answer 14

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

Question 15

What is a Nissen Fundoplication?

Answer 15

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

Question 16

What is a Belsey Mark IV Fundoplication?

Answer 16

270 degree wrap

Question 17

What is a Hill Repair?

Answer 17

Gastric cardia is anchored to the posterior abdominal wall

Question 18

What are the possible Oesophageal complications of Hiatus Hernias?

Answer 18

Intermittent bleeding
Oesophagitis
Erosions
Barrett's Oesophagus 
Oesophageal Strictures

Question 19

What are the possible Non-Oesophageal complications of Hiatus Hernias?

Answer 19

Incarceration of hiatus hernia (only with paraoesophageal hernias)
This can lead to strangulation and perforation

Question 20

What is the prognosis for patients with Hiatus Hernias?

Answer 20

Generally good

Sliding hernias have a better prognosis than rolling hernias