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Hiatus hernia

Medicine > Gastrointestinal

Background knowledge 🧠

Definition

  • Hiatus hernia is a condition where part of the stomach pushes up through the diaphragm into the chest cavity.
  • Commonly involves the gastroesophageal junction.
  • Can lead to gastroesophageal reflux disease (GORD).

Epidemiology

  • Affects approximately 10-20% of adults in the UK.
  • More common in individuals over 50 years old.
  • Higher prevalence in obese individuals.
  • Often asymptomatic and discovered incidentally.

Aetiology and Pathophysiology

  • Caused by weakening of the diaphragmatic muscles.
  • Increased intra-abdominal pressure (e.g., due to obesity, pregnancy, heavy lifting).
  • Congenital factors (e.g., short oesophagus).
  • Leads to displacement of the gastroesophageal junction and stomach.
  • Potential for acid reflux and mucosal damage.

Types

  • Sliding hiatus hernia: Most common type, where the gastroesophageal junction and stomach slide into the chest.
  • Paraesophageal hiatus hernia: Less common, part of the stomach pushes through the diaphragm next to the oesophagus.
  • Mixed hiatus hernia: Features of both sliding and paraesophageal hernias.

Clinical Features 🌡️

Symptoms

  • Often asymptomatic, especially in sliding hiatus hernia.
  • Heartburn, particularly after meals or when lying down.
  • Regurgitation of food or liquids into the mouth.
  • Dysphagia (difficulty swallowing).
  • Epigastric or chest pain, which may mimic angina.

Signs

  • May have no obvious clinical signs.
  • Epigastric tenderness on palpation in some cases.
  • Signs of GORD (e.g., dental erosion, laryngitis).
  • Rarely, visible or palpable mass in the epigastrium.

Investigations 🧪

Tests

  • Upper gastrointestinal (GI) endoscopy: First-line for visualizing the hernia and ruling out other conditions.
  • Barium swallow: X-ray study to assess the size and type of hernia.
  • Manometry: Measures oesophageal motility and LES pressure, useful in GORD assessment.
  • 24-hour pH monitoring: Assesses acid reflux severity.

Management 🥼

Management

  • Lifestyle changes: Weight loss, avoiding large meals, head elevation during sleep.
  • Medical treatment: Proton pump inhibitors (PPIs) for acid suppression, H2-receptor antagonists as alternatives.
  • Surgical intervention: Indicated in refractory cases or complications, e.g., laparoscopic fundoplication.
  • Regular monitoring: Necessary for symptomatic patients to prevent complications.

Complications

  • Gastroesophageal reflux disease (GORD).
  • Esophagitis and esophageal strictures.
  • Barrett’s esophagus (precancerous condition).
  • Incarceration or strangulation of the hernia (rare).
  • Iron-deficiency anemia due to chronic bleeding.

Prognosis

  • Generally good with appropriate management.
  • Surgical outcomes are typically positive, especially with laparoscopic techniques.
  • Risk of recurrence post-surgery is low but present.
  • Complication risk is higher in untreated or refractory cases.

Key Points

  • Common, often asymptomatic condition.
  • Important differential in patients presenting with chest pain and dysphagia.
  • Management involves a combination of lifestyle changes, medications, and possibly surgery.
  • Monitor for complications such as GORD and Barrett’s esophagus.

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Gastrointestinal