Hiatus hernia

A hiatal hernia is when there is a protrusion through the oesophageal hiatus (at T10). The stomach is the most common culprit.

Although it is difficult to tell as they are generally asymptomatic, it is estimated that 1/3rd of the population >50 years old has a hiatal hernia.

🔢 Classification

There are 2 main types of hiatal hernias:

Sliding hiatus hernia - this makes up 80% of the cases. In this instance, the gastro-oesophageal junction passes through the diaphragmatic hiatus. The cardiac notch is lost in this instance.
Rolling/para-oesophageal hiatus hernia - 20% of cases. Here the fundus of the stomach passes through completely, maintaining the cardiac notch and forming a true hernia. It also may increase in severity over time.

⚠️ Risk factors

Age - is by far the biggest factor. Diaphragmatic tone tends to decline as we age, coupled with increasing IAP and size of the hiatus, it makes sense.
Pregnancy
Obesity
Ascites
Calcium channel blockers - calcium channel blockers can relax the lower oesophageal sphincter, thus increasing reflux. They should be avoided if possible.

😷 Presentation

As stated earlier, the majority of patients are asymptomatic.

Reflux is a common symptom causing burning epigastric pain which worsens when lying flat. It may also be a non-cardiac chest pain.
Vomiting + weight loss are rare but are red flags.
Bleeding and anaemia may occur due to ulceration.
Hiccups
Palpitations
Dysphagia

Examination is typically normal, but if the hernia is large enough, sometimes bowel sounds may be auscultated in the thoracic cavity.

🔍 Investigations

📷

Imaging 🏆 OGD is the gold standard. We assess for upward displacement of the gastro-oesophageal junction.

🏆 Barium swallow X-ray - the most sensitive diagnostic investigation for hiatus hernia

CT or MRI may be used with a contrast swallow, but are less commonly used and a hiatus hernia is more of an incidental finding with these modalities.

🧰 Management

💊

Conservative treatment:

🥇 PPI remains the first line treatment. It aids symptom control.
Lifestyle control - should be advised (weight loss, low fat diets, smaller portions, earlier meals, raising head of bed).

Smoking + alcohol cessation is also important

🔪

Surgical treatment: Surgery may be indicated when:

One remains symptomatic after exhausting all conservative options.
Increased risk of strangulation/volvulus.
Gastric outlet obstruction leading to nutritional deficiencies.

Surgical options are:

Cruroplasty - the hernia is reduced back into the abdominal cavity and the hiatus is closed off. Mesh may be used for large defects.
Fundoplication - this aims to strengthen the LOS and keep the gastro-oesophageal junction in the correct position.

🚨 Complications

First let’s look of the untreated hiatus hernia:

Of course incarceration and strangulation are always risks.

Gastric volvulus is of major concern and will require emergency surgery. It can be indicated through Borchardt’s triad.

🥨

Borchardt’s triad:

Severe epigastric pain
Retching without vomiting
Inability to pass an NG tube

Secondly, let’s discuss complications of surgery:

Recurrence
Abdominal bloating as there may be an inability to belch.
Dysphagia
Fundal necrosis if the short gastric arteries have been disrupted (this is a surgical emergency and will require gastric resectioning).