Hiatal Hernia
Definition
A hiatal hernia is defined as the herniation (abnormal protrusion) of abdominal contents, most commonly the stomach, through the oesophageal hiatus of the diaphragm into the mediastinum.
Aetiology
Hiatral hernia typically results from progressive widening of the diaphragmatic oesophageal hiatus and weakening of the phrenoesophaela membrane.
- Age-related degeneration of connective tissue (major contributor)
- ↑ Intra-abdominal pressure (e.g. chronic coughing, obesity, heavy physical labour)
- Presence of GORD (both a contributing factor to and a consequence of hiatal hernia)
- Smoking and alcohol use
Classification
There are 4 anatomical types of hiatal hernia: [Ref]
| Type 1 (sliding hiatal hernia) | Most common type (90-95% cases are type 1)
The GOJ and the gastric cardia herniate through the diaphragm into the mediastinum |
| Type 2 (paraoesophageal hiatal hernia) | Part of the gastric fundus herniates through the diaphragm into the mediastinum
BUT, the GOJ remains in its normal anatomical position (i.e. under the diaphragm, not herniated) |
| Type 3 (mixed / combined) | Combined features of types 1 and 2 |
| Type 4 (complex) | In addition to the stomach, other abdominal organs (e.g. intestines, colon, spleen) herniate through the hiatus |
Type 1 vs type 2 is the most important differentiation to be aware of.
Clinical Features
Clinical presentations of hiatal hernia are highly variable, depending on the hernia type and size. [Ref]
Most hernias are asymptomatic and often discovered incidentally during imaging or endoscopy for unrelated reasons.
When symptomatic, they are most commonly related to gastro-oesophageal reflux: [Ref]
- Heartburn (retrosternal chest pain)
- Regurgitation
- Larger hernias and esp. type 2 hernia may cause dysphagia and post-prandial bloating
Acute presentations are rare, but clinically significant, including: [Ref]
- Incarceration
- Strangulation
- Perforation
Investigation and Diagnosis
Test of choice: barium swallow (specifically a double-contrast upper GI series) [Ref]
- Confirms a hiatal hernia by visualising the contrast-filled stomach and/or GOJ above the diaphragm
- It also provides detailed anatomical and functional information, also allows classifying the hiatal hernia type
Upper GI endoscopy is a complementary tool for mucosal assessment, but NOT the primary diagnostic tool to confirm a hiatal hernia [Ref]
- Endoscopy has moderate sensitivity and specificity for hiatal hernia detection, limited by the mobility of the GOJ and the inability to visualise the anatomical relationship between the GOJ and the diaphragm
- However, many hiatal hernias are detected incidentally on endoscopy
Chest X-ray findings:
- Retrocardiac air-fluid level (represents a herniated stomach in the posterior mediastinum)
Chest X-ray is NOT routinely performed for the evaluation of hiatal hernias; findings are often noticed incidentally (i.e. when the chest X-ray is performed for unrelated reasons)
Management
Approach: [Ref]
- Active observation for an asymptomatic, small sliding hiatal hernia (type 1)
- 1st line intervention: medical management (for symptomatic hernias)
- 2nd line intervention: surgery (for persistent or severe symptoms / refractory to medical therapy / large hernia >5cm / presence of complications)
Medical Management
Mainstay of management: PPIs (e.g. omeprazole, lansoprazole)
Regarding long-term treatment with PPI, advise:
- Long-term PPI is not routinely recommended
- Use the lowest effective dose to control symptoms
- If possible, step down or stop treatment
- Consider self-treatment with antacid and/or alginate therapy, although not recommended for long-term or continuous use
Key long-term complications of PPI use:
- Risk of infections – C. difficile infection, pneumonia
- Electrolyte deficiencies – hyponatraemia, hypomagnesaemia
- Malabsorption – iron deficiency, risk of osteoporosis (from impaired calcium absorption)
- GI effects – rebound acid hypersecretion when stopped suddenly, hypergastrinaemia → fundic gland polyps
Surgical Management
Mainstay is laparoscopic repair with the following key operative steps: [Ref]
- Reduction of the hernia sac
- Restoration of intra-abdominal oesophageal length (at least 3 cm)
- Crural closure (primary suture usually)
- Fundoplication (to prevent post-operative reflux)