Hiatus hernia

Discipline : Gastroenterology

Definition

• Sliding hiatus hernias are the most common type of hiatus hernias@1708755861030
• A type I hiatal hernia is a sliding hiatal hernia@1708756162420
• A type II hiatal hernia is a paraoesophageal hiatal hernia@1708757487890
• A type III hiatal hernia is a mixed hiatal hernia@1708757488010
• A type IV hiatal hernia is a complex hiatal hernia@1708757493311

• Type IV is associated with herniation of abdominal structures other than the stomach (e.g. spleen)

Risk Factors

Age : phrenooesophageal ligament weakens

Obesity : deposition of fat in and around the crura → widened hiatus

Smoking : loss of elastin fibres in the diaphragmatic crura

Prolonged periods of increased intra-abdominal pressure - Pregnancy - Ascites - Chronic cough - Chronic constipation

Clinical Features

• Most hiatal hernias are asymptomatic and require no medical or surgica intervention

• Type 1 hiatus hernia patients have symptoms similar to Gastroesophageal Reflux Disease (GORD) @1708757493436

• The saint triad is a common triad of pathologies consisting of cholelithiasis, diverticulosis, and hiatal hernia @1708757679935

Investigations and diagnosis

• Barium swallow
• Endoscopy
• Often incidentally found on chest X-ray

Management

• Non-pharmacological
  • Same as Gastroesophageal Reflux Disease (GORD)
• Pharmacological
  • PPIs
• Surgery
  • Laparoscopic/open fundoplication and hiatoplasty
    • Indicated when:
      • Persistence of symptoms despite conservative management
      • Refusal or inability to take long-term PPIs
      • Severe symptoms/complications of gastroesophageal reflux disease: bleeding, strictures, ulcerations

Complications

• Type I has similar complications to Gastroesophageal Reflux Disease (GORD)
• Complications of II, III, IV:
  • Upper GI bleeding → Iron deficiency anaemia
  • Gastric ulcers
  • Gastric perforation
  • Gastric volvulus
  • Total gastric obstruction
    • Total gastric obstruction is characterised by Borchadt triad which is severe epigastric pain, unproductive retching and inability to pass a NG tube @1708758549035

Sources

Amboss : hiatus hernia