Hiatus Hernia

Definitions

• Sliding hiatus hernias are the most common type of hiatus hernias
• A type I hiatal hernia is a sliding hiatal hernia
• A type II hiatal hernia is a paraoesophageal hiatal hernia
• A type III hiatal hernia is a mixed hiatal hernia
• A type IV hiatal hernia is a complex hiatal hernia

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 for example from:
  • 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)
• The saint triad is a common triad of pathologies consisting of cholelithiasis, diverticulosis, and hiatal hernia

Investigations and diagnosis

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

Management

• Non-pharmacological
  • Same as 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 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
• Cameron lesions