Hiatus Hernia

For all the abbreviations, there is not enough alliteration in medicine.


Hiatus Hernia

Definition:

Sliding hiatus hernia (80%)- the gastro-oesophageal junction slides up into the chest

Rolling hiatus hernia (20%)- the gastro-oesophageal junction remains in the abdomen but a bulge of stomach herniates up into the chest alongside the oesophagus

Image result for hiatus hernia

Aetiology/ risk factors:

-congenital or acquired e.g. thinning and increased laxity of the phreno-oesophageal ligament with age

-associated with obesity, GORD, chronic oesophagitis

Epidemiology: common

-Seen in 30% of Gastro-Oesophageal Reflux Disease (GORD) patients > 50 years old, especially obese women

-50% of patients with hiatus hernias have symptomatic GORD.

Symptoms:

-In sliding hiatus hernias, acid reflux often happens as the lower oesophageal sphincter becomes less competent.

-heartburn

-indigestion

-prostprandial fullness

-regurgitation

-In rolling hiatus hernias, acid reflux is uncommon as the gastro-oesophageal junction remains intact.

Signs: generally, no specific signs

Investigations:

Barium swallow- best diagnostic test

Image result for hiatus hernia barium swallow

Upper GI endoscopy- visualises the mucosa, may show complications such as oesophagitis, ulceration and Barrett’s oesophagus, but cannot reliably exclude a hiatus hernia

Chest X-ray- large hernias can appear as a gastric bubble behind the heart

Image result for hiatus hernia CHEST X RAY

High resolution manometry- can diagnose sliding hernias (GI motility diagnostic system that measures intraluminal pressure activity)

Management:

-lose weight, avoid late meals

-treat reflux symptoms (antacids or alginates, PPIs)

Surgical repair if intractable symptoms despite optimum medical therapy, or complications. It is advisable to repair rolling hiatus hernias prophylactically (even if asymptomatic) as they may strangulate, requiring prompt surgical repair.

Surgery involves hernia reduction, crural repair (tendons of the diaphragm which attach to vertebrae), combined with antireflux fundoplication e.g. Nissen’s fundoplication.

Image result for nissen's fundoplication

Complications:

GORD and its complications

-GORD ⇒ Barrett’s Oesophagus ⇒ Oesophageal Adenocarcinoma

-oesophagitis, oesophageal ulceration

-benign oesophageal stricture

-reflux asthma, cough and laryngitis syndromes

 

-Rarely- incarceration, strangulation or perforation of hernia

-Rolling hernias can enlarge and progress to where the entire stomach is within the thoracic cavity, causing respiratory problems.

Prognosis: generally good, with most not causing severe problems. Sliding hernias have a better prognosis than rolling hernias.

References: Rapid Medicine, Cheese & Onion
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