Hiatal Hernias

Classic Clinical Vignette45 y/o guy presents to ED with chest pain, difficulty swallowing, and heartburn after meals, especially when reclining. His CXR is shown on the right.

What is a Hiatal Hernia?• Herniation of stomach through diaphragm into the chest cavity• 2 key types of hiatal hernias: Sliding vs Paraesophageal

• Technically, there are 4 types according to Hill’s Classification – but Sliding Hiatal Hernia and Paraesophageal Hiatal Hernia are the 2 that are MC tested

Type 1 vs Type 2 Hiatal HerniaType 1 Type 2Stomach slides into mediastinum Stomach fundus rolls through

diaphragmOccurs at GEJ GEJ remains intra-abdominal80% of cases associated w/GERD Parallel to esophagus

Other Types of Hiatal Hernia• Type 3: Combination of Type 1 and Type 2• Type 4: Abdominal organ (eg colon or spleen) +/- stomach herniate

into chest cavity

Epidemiology• Estimated 10% of adult population in US has a hiatal hernia!• Occurs most commonly in women in their 5th and 6th decades• Type 1 (~95%) > Type 2 (5%)

Risk Factors• Age - biggest risk factor, related to loss of diaphragmatic tone• Pregnancy• Obesity• Ascites

Due to ↑ intra-abdominal pressure and superior displacement of viscera

Presentation (S/Sx)Symptoms:• May be asymptomatic (identified

incidentally)• Heartburn• Chest pain• Abdominal pain• GERD (especially in sliding hiatal hernias)• Dysphagia with solids• Belching

Physical Exam:• Usually significant findings∅• May hear bowel sounds in chest

Workup ★ Usually an incidental finding

• Barium Swallow: VERY helpful in establishing diagnosis; Shows anatomy & size of hernia, orientation of stomach, and location of GEJ

• CXR: Retrocardiac air bubble (air-fluid level in posterior mediastinum); however, CXR may be normal• CT scan/MRI: Stomach is partially or completely intrathoracic +/- herniation of other intra-

abdominal organs into chest• Esophageal manometry: Double hump configuration on manometry; pH may be abnormal as well• Upper Endoscopy: Helps to rule out other esophageal/gastric pathologies; Retroflexion maneuver

can be used to detect paraesophageal hernias• Ambulatory pH testing: Helps in planning appropriate intervention and to establish a baseline of

acid reflux for follow-up

Barium Swallow - Images

Source: 2017 UpToDate

DDx• Diffuse Esophageal Spasm (DES):

Manometry → Large # of non-peristaltic esophageal contractions• Nutcracker Esophagus: Manometry →

esophageal contractions are peristaltic but of large amplitude• Achalasia: Manometry → LES is

hypertensive & fails to relax in swallows• GERD: Incompetent LES• Other important DDx to consider and

exclude are: Cardiac chest pain, Pancreatic cancer, Esophageal cancer, Gastric cancer

Esophageal motility disordersW.G. Paterson, Raj K. Goyal and Fortunée Irene HabibGI Motility online (2006)doi:10.1038/gimo20

DDx continued• Other important differential to consider and exclude are:• Cardiac chest pain• Pancreatic cancer• Gastric cancer

Management• Sliding Hiatal Hernia – Surgical repair of an isolated Type 1 Hiatal Hernia

is usually not needed. Mgmt consists of addressing associated GERD. 1st line therapy consists of PPI (eg omeprazole) and lifestyle modifications (eg weight loss, low fat, earlier meals, smaller portions). If symptoms persist despite maximal medical tx, surgery may be considered.• Paraesophageal Hiatal Hernia – If symptomatic → surgical repair is

indicated. Emergent surgical repair may be needed in pts with gastric volvulus, perforation, gastric outlet obstruction, strangulation and/or respiratory compromise secondary to the paraesophageal hernia. Mgmt of asymptomatic paraesophageal hiatal hernias is somewhat more controversial - however, most experts are opposed to PPx surgical repair.

Paraesophageal Hernia Repair (PEHR)• Can be performed either transabdominally or transthoracically• Transabdominal repair consists of complete mediastinal hernia sac dissection and

reduction, relocating GEJ intra-abdominally, stable crural closure, antireflux procedure (eg Nissen fundoplication), and intra-abdominal gastric fixation

• Transabdominal repair can be done laparoscopically or open. Laparoscopic transabdominal PEHR preferred in most pts, both in elective and emergent cases• Note: Laparoscopic PEHR has higher (but clinically insignificant) radiographic recurrence rate

than the other two approaches (transabdominal open and transthoracic)

• Transthoracic approach typically reserved for pts who failed previous open transabdominal repair

• Routine use of mesh during PEHR is not recommended (Grade 2C) – due to potential for complications (eg erosion or stenosis of esophagus)

Post Op Care for Transabdominal PEHR• Admission to hospital• Antiemetics for first 24 hrs - post-op vomiting → disruption of repair

and possible early recurrence• Barium swallow on POD 1 - to assess for esophageal leaks or early

recurrence & to evaluate gastric emptying/motility• Discharge - usu on POD 2 if laparoscopic PEHR, POD 5 for open PEHR• Low residue diet - recommended for 2-3 wks following discharge

References• Kahrilas PJ. Hiatus Hernia. In: UpToDate, Post TW (Ed). UpToDate, Waltham, MA. Accessed

on March 10, 2017• Klingensmith M. The Washington Manual Of Surgery. 1st edition. Lippincott Williams &

Wilkins. 2008.• Hiatus Hernia. TeachMeSurgery.com. 2016. Available from

http://teachmesurgery.com/general/gastric/hiatus-hernia/. Accessed on March 10, 2017.• Paterson WG, Goyal RK, Habib FI. Esophageal motility disorders. GI Motility Online (2006).

doi: 10.1038/gimo20.• Rosen M, Blatnik J. Surgical management of paraesophageal hernia. In: UpToDate, Post

TW (Ed), UpToDate, Waltham, MA. Accessed on March 10, 2017.