Hiatal hernia

• 55%-60% of individuals over the age of 50 have a hiatal hernia
• However 9% of these suffer heartburn 🡪 associated position and obesity
• Unknown cause

predisposing factor

= intraabdominal pressure = is a result of

• obesity
• pregnancy
• chronic constipation
• COPD
• previous surgeries

Types

• two main types of hiatus hernia (although they may co-exist):
  • sliding hiatus hernia (>90%)
  • rolling (para-oesophageal) hiatus hernia (<10%)
• Some divide them into four types:
  • type 1: sliding hiatal hernia (~95%)
  • type 2: paraoesophageal hiatal hernia with the gastro-oesophageal junction in a normal position
  • type 3: mixed or compound type, paraoesophageal hiatal hernia with displaced gastro-oesophageal junction
  • type 4: mixed or compound type hiatal hernia with additional herniation of viscera

• Subtypes
  • Sliding hiatus hernia
    • This is the most common type of hiatus hernia (~90%)
    • The gastro-oesophageal junction (GOJ) is usually displaced >2 cm above the oesophageal hiatus. 
  • Rolling (paraoesophageal) hiatus hernia
    • The rolling (paraoesophageal) hiatus hernia is much less common than the sliding type. 
    • The GOJ remains in its normal location while a portion of the stomach herniates above the diaphragm

Can be asymptomatic or have symptoms 

• epigastric fullness 
• postprandial distress
• regurgitation
• nausea
• chest pain
• cough
• gastroesophageal reflux disease (GERD):
  • due to incompetence of the cardiac sphincter
  • ‘heartburn’ after meals that is made worse by stooping or lying down
  • studies in Western countries have reported that over half of patients (50% to 94%) with reflux esophagitis had concomitant hiatal hernias (prevalence of hiatal hernia in the control subjects were 13% to 59%)

• regurgitation of food at night, leading to aspiration pneumonia
• dysphagia
  • in part caused by reflux but also due to inefficient peristalsis resulting from movement of the hernia upwards as the oesophagus contracts

• duodenal or gastric ulcer
• Saint’s triad
  • (1) sliding hiatus hernia is associated with
  • (2) gallstones
  • (3) diverticular disease
• Waterbrash – tasting acid regurgitated from the stomach; this is a characteristic bitter taste.
• nausea and vomiting are common in children but not in adults
• children may present as failure to thrive, and with anaemia

Diagnosis

• Xray:
  • Xray – sensitivity of 50-70%.
  • retrocardiac air-fluid level / intrathoracic stomach
  • x-rays are not sensitive enough to diagnose small or sliding hiatus hernias
• Upper GI endoscopy:
  • Sensitivity around 95% and specificity is around 95%.
• Barium swallow:
  • Sensitivity  is around 70% and specificity is around 90%.
• Esophageal manometry: 

• Sensitivity is around 85% and specificity is around 95%
• CT
  • not a standard procedure in the investigation of hiatus hernia
  • useful in – assessing gastric volvulus in patients with paraesophageal hernia and to detect other herniated organs

Management

• Asymptomatic hernias
  • may not require treatment
• HH with reflux disease
  • can be managed medically
    • Proton pump inhibitors (PPIs)
    • Histamine 2 receptor antagonists
    • antacids
• lifestyle modification
  • weight loss
  • avoidance of “trigger” foods
  • eat frequent small meals, and not to eat just before bedtime
  • not to lie down after eating a meal and advice to sleep with their head elevated
    • by extra pillows.
    • elevating the head of the bed by 6-8 inches (15-20 cm) and avoidance of food three hours before bedtime is especially helpful for patients who are prone to symptoms at night 
  • patients should be dissuaded from smoking.
• Paraesophageal hernias
  • require surgical intervention

Complications:

• Bleeding
• Perforation
• Strangulation
• obstructed