Gastroenterology
Hiatal Hernia
Background
- Definition
- Herniation of the stomach (and occasionally other abdominal organs) through the esophageal hiatus into the thoracic cavity
- Also known as:
- Diaphragmatic hernia
- Hiatus hernia
- Synopsis
- Acquired hernias
- Most cases are asymptomatic
- If present, symptoms resemble esophagitis or GERD
- Congenital hernias
- Usually symptomatic at birth
- Large defects are not compatible with life unless surgically corrected
Pathophysiology
- Mechanism
- Main etiologies
- Age-related degeneration
- Prolonged stretching of the GE junction
- Increased intraabdominal pressure
- Congenital (rare)
- Possible rupture of the phrenoesophageal ligament
- Development of hernia
- Diaphragmatic hiatus transforms from a small fissure to a true oval opening formed by the diaphragmatic muscles
- Exposure of esophageal mucosa to gastric acid
- Associated with larger hernias
- Cameron lesions
- Small ulcerative lesions on herniated gastric mucosa
- Found at the level of diaphragm
- Likely due to ischemia caused by gastric wall sliding in and out of the thoracic cavity
- May lead to GI bleeding
- Types of acquired hiatal hernia
- Type 1: sliding hernia (95% cases)
- Protrusion of GE junction or gastric cardia through the esophageal hiatus
- Phrenoesophageal ligament becomes more lax but remains intact
- Hernia may slide in and out of thoracic cavity
- Consequently, the size of hernia may vary
- Frequently associated with loss of tone of the lower esophageal sphincter (LES)
- Type 2: paraesophageal "rolling" hernia (5% cases)
- Partial protrusion of the stomach into the thoracic cavity
- Associated with mechanical complications (volvulus)
- Usually due to partially damaged phrenoesophageal ligament
- Gastric fundus "rolls" into thoracic cavity
- Usually located to the left of distal esophagus
- GE junction remains at the level of diaphragm
- In extreme cases, most of the stomach may herniate into thoracic cavity
- Type 3: mixed hernia (rare)
- Features of type 1 and type 2
- Usually begins as type 2 hernia
- Sliding component develops over time
- Type 4:
- Protrusion of other intraabdominal organs
- Associated with large defects of phrenoesophageal ligament
- Herniated organs may include:
- Stomach
- Spleen
- Pancreas
- Omentum
- Colon
- Small intestine
- Etiology/Risk Factors
- Repetitive vomiting
- Pregnancy
- Obesity
- Power athletes
- Genetic predisposition
- Autosomal dominant inheritance has been reported in some families with type 1 hiatal hernia
- High concordance rate in identical twins
- Epidemiology
- Incidence/Prevalence
- Acquired hiatal hernia
- Found in 55-60% of persons aged > 50 yo
- Up to 80% of power athletes
- Prevalence increases with age
- Sliding hernia > paraesophageal hernia (100:1)
- Sliding hernia
- Paraesophageal hernia
- More common in N America and W. Europe as opposed to rural Africa
- Mortality/Morbidity
- Associated with:
- GERD
- Esophagitis
- Diverticulosis
- Duodenal ulcers
- Gallstones
Diagnostics
- History/Symptoms
- Acquired hernias
- Most cases are asymptomatic
- If present, symptoms resemble esophagitis or GERD:
- Heartburn
- Epigastric pain
- Regurgitation
- Dysphagia
- Chest pain
- Postprandial fullness
- Hoarseness
- Physical Exam/Signs
- No characteristic physical exam findings
- Diagnosis largely based on history of esophagitis or GERD, and evidence provided by diagnostic imaging
- Often diagnosed incidentally
- Findings may include:
- Oral cavity
- Dental enamel erosion
- Throat erythema
- Auscultation
- Bowel sounds over the left lung base
- Palpation
- Regurgitated food should be noted if digested or undigested
- Undigested food may reveal different pathology (e.g., achalasia or diverticulum)
- Rule out other etiologies
- Labs/Tests
- No specific lab findings
- CBC +Diff, CMP
- Iron deficiency anemia may be present
- WBC count
Consider testing to rule out other conditions
- Imaging
- CXR
- Consider as initial test in symptomatic patients
- AP view (View image), Lateral view (View image)
- Note retrocardiac air bubble
- Upper GI series
- Barium contrast
- Preferred examination for suspected hiatal hernia
- Presence of gastric cardia 2 cm above the hiatus
- Not required if endoscopy ordered
- CT/MRI (View image)
- Assess herniation of other abdominal organs
- Indicated for equivocal cases
- Ultrasound (abdominal)
- Esophageal diameter of ≥ 18 mm at the diaphragm
- Other Tests/Criteria
- Endoscopy
- Upper GI
- Allows for direct visualization of hernia and assessment of complications
- Esophageal manometry
- Low sensitivity, high specificity
- Rarely performed
- May help establish the diagnosis in conjunction with endoscopy findings
- pH monitoring
- Gold standard for dx of acid reflux
- Probe placed 5 cm above GE jxn and measures amount of acid to which exposed
- Differential Diagnosis
Treatment
- Initial/Prep/Goals
- ABCs, monitors
- Conservative management
- Eat 5-6 small meals per day
- Do not lie down soon after eating
- Sleep with head of bed elevated
- Avoid consumption of large amounts of food
- Avoid foods and medications that decrease LES tone
- Calcium channel blockers (CCB)
- Anticholinergics
- Caffeine
- Mint
- Chocolate
- Weight loss
- Medications
- H2 antagonists
- Indicated for symptomatic disease (heartburn)
- PPIs
- Indications
- Symptomatic disease (heartburn)
- Esophagitis
- Refractory cases
- Medical/Pharmaceutical
- Surgical/Procedural
- Surgical management
- Indications
- Refractory symptoms
- GI bleeding
- Congenital hernia
- Ulcer
- Stricture
- Barrett's mucosa
- Paraesophageal hernias
- All symptomatic pts
- Asymptomatic large hernias in pts < 60 yo and healthy
- Nissan fundoplication (360-degree wrap)
- Complete wrapping of GEJ using fundus of stomach
- 52 French bougie in place
- Ensures approp. approx. w/o wrap being too tight
- Dissection of short gastric vessels off the greater curvature of the stomach to mobilize the fundus
- Phrenoesophageal membrane over left crus full dissected and crural fibers identified
- For right crural dissection, lesser omentum is opened and right phrenoesophageal membrane mobilized
- Note: pressure anterior and posterior vagi during dissection
- Pentose drain is placed around the esophagus to assist mobilization and creation of the wrap
- Wrap is created over a length of 2.5 to 3 cm using 3-4 interrupted permanent sutures
- When wrap complete, 52 French bougie is removed, wrap is anchored to esophagus and hiatus
- This prevents herniation and slippage
- Partial fundoplication (Dor and Toupet)
- Procedure of choice when esophageal motility is poor
- 2 most common partial fundoplication are
- Dor procedure
- Anterior wrap
- Performed by folding fundus over the anterior aspect of the esophagus
- Then anchoring it to hiatus and esophagus
- Used at times for tx of GERD
- More commonly used in pts w/ achalasia who have undergone anterior myotomy
- Toupet procedure
- Posterior wrap
- Esophageal dissection (same as Nissen), w/ mobilization of esophagus
- Creates 220-250-degree wrap around posterior aspect of esophagus
- Procedure of choice for motility concern
- They involve creating a 180 to 250-degree wrap
- Partial wrap will help prevent obstruction in esophagus when motility a concern
- Complications
- GERD
- Esophagitis
- Barrett's esophagus
- Esophageal stenosis
- Strangulation / volvulus
- GI bleeding
- Lung collapse
- Aspiration pneumonia
- ENT disorders
- Heart failure
- Prevention
- Weight loss
- Avoidance of strenuous physical activity associated with increased intraabdominal pressure
Disposition
- Admission Criteria
- Consults
- Gastroenterology
- Indicated for refractory cases
- Surgery
- Refractory cases of acquired hiatal hernia
- Congenital diaphragmatic hernia
- Pulmonology
- Extra-esophageal symptoms of GERD
- Laryngeal/pulmonary symptoms
- Discharge/Follow-up Instructions
- Follow-up with primary care or gastroenterologist in 2-4 weeks
References
- Reddy RM, Meyers BF. Esophagus. In: Klingensmith ME, Chen LE, Glasgow SC; (eds). The Washington Manual of Surgery, 5th ed. Philadelphia, PA:Lippincott Williams & Wilkins, 2007;Chapter 8
- Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22(4):601-616
- Naunheim KS, Edwards M. Paraesophageal Hiatal Hernia. In: Shields TW, LoCicero III J, Reed CE, Feins RH; (eds). General Thoracic Surgery, 7th ed. Philadelphia, PA:Lippincott Williams & Wilkins, 2009;Chapter 155
- Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Guidelines for the Management of Hiatal Hernia. Available at: http://www.sages.org/publications/guidelines/guidelines-for-the-management-of-hiatal-hernia/. [Accessed June 2022]
- Kimer N, Schmidt PN, Krag A. Cameron lesions: an often overlooked cause of iron deficiency anaemia in patients with large hiatal hernias. BMJ Case Reports Oct 2010;2010
- Ferri F. Hiatal Hernia (PTG). In: Ferri F; (eds). Ferri's Clinical Advisor 2015: 5 Books in 1. Philadelphia, PA:Elsevier-Mosby, 2014;pg.571
- Neumeyer L, McGregor DB, Mann B. Abdominal Wall, Including Hernias. In: Lawrence PF, Bell RM, Dayton MT; (eds). Essentials of General Surgery, 4th ed. Philadelphia, PA:Lippincott Williams & Wilkins, 2005;Chapter 12
- Bredenoord AJ, Smout AJPM. Hiatus Hernia and Gastroesophageal Reflux Disease. In: Richter JE, Castell DO; (eds). The Esophagus, 5th ed. Oxford, UK:Wiley-Blackwell, 2012;Chapter 20
- Hiatal Hernia. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK562200/. [Accessed June 2022]
Contributors
- Ballarin, Daniel, MD
- Singh, Ajaydeep, MD
Updated/Reviewed: June 2022