Paraesophageal hernia

Question 1

What is hiatal hernia type is more likely to present with symptoms of obstruction: a sliding (type I) or paraesophageal (type II)?

Answer 1

Type II

Question 2

What is the pathology seen in a type I hiatal hernia?

Answer 2

An attenuated phrenoesophageal ligament, there is no true hernia sac

Question 3

What is the most common hiatal hernia?

Answer 3

Type I (sliding)

Question 4

Are hiatal hernias more common in women or men?

Answer 4

Women, and more common in the 5th-6th decade.

Question 5

Where is the GE junction in a true type II hiatal hernia?

Answer 5

Intraabdominal

Question 6

Where is the GE junction in a type I hiatal hernia?

Answer 6

Intrathoracic

Question 7

What are the clinical and radiographic findings concerning for a paresophageal hiatal hernia?

Answer 7

In ability to pass an NG tube, CXR showing air fluid levels in the mediastinum.

Question 8

A 58 year old patient presents with acute onset of chest pain, nausea and retching. CXR shows an air fluid level in the mediastinum, and you are unable to pass an NG tube. What is the diagnosis and definitive management?

Answer 8

This patient is presenting with classic findings of Borchardt’s triad: chest pain, retching with inability to vomit, and inability to pass an NG tube. The diagnosis is an incarcerated paraesophageal hernia, and is a surgical emergency.

Question 9

What is a type III hiatal hernia?

Answer 9

Combination of Type I and II, with in intrathoracic GE junction AND herniation of gastric fundus and body into the chest.

Question 10

What percentage of patients with type II hiatal hernias present with anemia?

Answer 10

Up to one third

Question 11

Anemia in type II hiatal hernias is caused by what?

Answer 11

Linear ulceration of the gastric cardia resulting from the proximal stomach’s repetitive movement across the diaphragm.

Question 12

What percentage of patients will have resolution of anemia after surgical correction of hernia?

Answer 12

92%

Question 13

Are 24 hr pH monitoring and motility studies useful for type II or III hernias in the workup of hiatal hernias?

Answer 13

No. the distortion of the GEJ and distal esophagus makes motility studies difficulty to interpret.

Question 14

When is repair generally recommending for hiatal hernias?

Answer 14

In symptomatic patients, esophageal mucosal damage (esophagitis/Barrett’s), or anemia, and in select asymptomatic patients.

Question 15

What is a Type I hiatal hernia?

Answer 15

Sliding hernia

Question 16

What is a type IV hiatal hernia?

Answer 16

Combo hernia with herniation of gastric fundus, body and other intraabdominal organs (colon, spleen, small bowel)

Question 17

Where is the location of type III and IV hernias?

Answer 17

Intrathoracic

Question 18

When symptomatic, how does type I hiatal hernia typically present?

Answer 18

GERD symptoms (mostly heartburn and regurgitation)

Question 19

When symptomatic, how do type II and III hernias typically present?

Answer 19

Epigastric or chest pain, postprandial discomfort or fullness, abdominal bloating, dysphagia, or respiratory symptoms.

Question 20

What causes the symptoms experienced in patients with type II or III hiatal hernias?

Answer 20

Hiatal outflow restriction, altered gastric anatomy and distension of intrathoracic portion of the stomach with esophageal or pulmonary compression.

Question 21

What is the traditional view regarding repair of type II or III hiatal hernias?/

Answer 21

All type II or III hernias should undergo surgical repair regardless of symptoms, due to increased mortality rate.

Question 22

Is the presence of a type I hiatal hernia an indication for surgery?

Answer 22

No. Most patients with type I hiatal hernia are asymptomatic. However, those with symptoms of GERD, chest pain, dysphagia may benefit from repair.

Question 23

What are the important operative points in repair of hiatal hernia?

Answer 23

Adequate esophageal dissection to establish adequate esophageal length, return GEJ to intraabdominal position, resection of hernia sac, reduction of herniated content to anatomically correct position, repair hiatal defect.

Question 24

What is the work up for hiatal hernia?

Answer 24

CXR, or contrast esophagram, EGD (to assess distal esophagus and stomach for concomitant pathology)

Question 25

Should antireflux procedures accompany all hiatal hernia repairs?

Answer 25

No. Of benefit in type I hernias who present with symptoms of severe GERD, but controversy in type II, because most patients do not have symptoms.

Question 26

What is a type II hiatal hernia?

Answer 26

A true paraesophageal herniation, with GEJ in normal anatomic location, (intraabdominal), and fundus of stomach alongside esophagus into the chest