Updated: 8/6/2019

Hiatal Hernia

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Snapshot
  • A 55-year-old man presents to the emergency room for palpitations and shortness of breath. He never had this problem before but notes that this has been progressive since he started heavy weight lifting training. He also notes regurgitation and a feeling of food being stuck before passing.
Introduction
  • Overview
    • a hernia through the esophageal hiatus of the diaphragm such that abdominal contents enter the chest
      • treatment is usually lifestyle modifications and antacids, but surgery may be required
  • Epidemiology
    • incidence
      • under detected due to asymptomatic hernias
    • demographics
      • majority are >50 years old
    • location
      • esophageal hiatus within diaphragm
    • risk factors
      • obesity
      • older age
      • trauma
      • valsalva 
  • Pathogenesis 
    • mechanism 
      • sliding (type I, >95%) 
        • gastroesophageal junction (GEJ) herniating through diaphragm
      • paraesophageal (type II, III, IV; <10%)
        • gastric fundus herniating through the diaphragm with the GEJ remaining below the diaphragm
  • Associated conditions
    • gastroesophageal reflux 
  • Prognosis
    • treatment relieves most symptoms
Presentation
  • Symptoms 
    • majority are asymptomatic 
    • common symptoms 
      • location 
        • epigastric pain  
        • substernal regurgitation and dysphagia 
        • chest palpitations and shortness of breath 
      • duration
        • intermittent
  • Physical exam
    • noncontributory to diagnosis
    • inspection
      • obesity
Imaging
  • Barium upper gastrointestinal radiograph series
    • indications
      • often after incidentally noted on plain chest radiograph 
      • clinical suspicion
    • findings
      • typically an outpouching of barium at the lower end of the esophagus 
    • sensitivity
      • most sensitive diagnostic test for paraesophageal hernias
      • poor sensitivity for small sliding hernias
Studies
  • Invasive studies
    • endoscopy
      • indications
        • evaluate for suspected complications
      • findings 
        • herniation through the diaphragm in retroflexed view 
        • erosive disease
        • Barrett esophagus or neoplasm
      • sensitivity and specificity
        • poor sensitivity for small sliding hernias
    • esophageal high-resolution manometry
      • uncommonly used 
Differential
  • Diffuse esophageal spasm 
    • key distinguishing factors
      • uncoordinated esophageal contractions
      • no hernia
  • Achalasia 
    • key distinguishing factors
      • high lower esophageal tone
      • no hernia
  • Gastroesophageal reflux disease 
    • key distinguishing factors
      • no hernia
Treatment
  • Lifestyle 
    • elevate head of bed, and avoid lying down after eating
      • indications
        • all patients
    • weight loss
      • indications
        • overweight patients
  • Medical 
    • antacids
      • indications
        • all patients
      • modalities
        • proton pump inhibitors
        • histamine H2 receptor antagonists
  • Surgical 
    • Nissen fundoplication (common)
      • indications
        • severe symptoms
        • erosive complications
        • large hernia
        • risk of gastric strangulation
Complications
  • Gastric strangulation
  • Barrett esophagus 
  • Aspiration pneumonia
  • Malnutrition
  • Gastrointestinal bleed
    • Cameron lesion: linear erosions where the stomach is constricted at the level of the hiatal hernia 
 

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