From the Guidelines
A 43-year-old female with a hiatus hernia found on OGD should be treated with lifestyle modifications and medication therapy, prioritizing proton pump inhibitors (PPIs) such as omeprazole 20mg once daily, as this approach has been shown to be effective in managing symptoms and improving quality of life 1.
Treatment Approach
The treatment of a hiatus hernia typically depends on the severity of symptoms. For mild to moderate symptoms, the following lifestyle modifications are recommended:
- Weight loss if overweight
- Avoiding meals within 3 hours of bedtime
- Elevating the head of the bed by 6-8 inches
- Avoiding trigger foods (spicy, fatty, acidic foods, chocolate, caffeine, and alcohol)
Medication Therapy
Medication therapy should include a proton pump inhibitor (PPI) such as omeprazole 20mg once daily before breakfast for 4-8 weeks 1. If symptoms persist, the dose can be increased to 40mg daily. For breakthrough symptoms, adding an H2 blocker like ranitidine 150mg at bedtime or an antacid such as Gaviscon after meals and at bedtime may be beneficial 1.
Surgical Intervention
If symptoms are severe or don't respond to medical therapy after 8-12 weeks, or if complications like stricture or significant regurgitation occur, surgical intervention (fundoplication) may be considered 1.
Importance of Follow-up
Regular follow-up is important to monitor symptom control and adjust treatment as needed. This approach prioritizes the patient's quality of life and minimizes the risk of complications associated with hiatus hernia 1.
Diagnosis and Inspection
A hiatus hernia is best inspected while in retroflexion, allowing for the assessment of both hiatal size and integrity of the oesophagogastric junction (OGJ) 1. Biopsies from two different regions in the oesophagus should be taken to rule out eosinophilic oesophagitis in those presenting with dysphagia/food bolus obstruction, where an alternate cause is not found 1.
From the Research
Hiatus Hernia Diagnosis and Treatment
- Hiatus hernia refers to conditions in which elements of the abdominal cavity, most commonly the stomach, herniate through the oesophageal hiatus into the mediastinum 2.
- The most common type of hiatus hernia is type I or sliding hiatus hernia, which is associated with laxity of the phrenooesophageal membrane and the gastric cardia herniates 2.
- Sliding hiatus hernia can be diagnosed by barium swallow radiography, endoscopy, or manometry when greater than 2 cm in axial span 2.
Hiatus Hernia and Gastroesophageal Reflux Disease (GERD)
- Hiatal hernia is a key factor in determining the lansoprazole dosage required for effective intra-oesophageal acid suppression in patients with GERD 3.
- Patients with hiatal hernia may require a higher dosage of lansoprazole to achieve effective intra-oesophageal acid suppression 3.
- GERD is defined by recurrent and troublesome heartburn and regurgitation or GERD-specific complications and affects approximately 20% of the adult population in high-income countries 4.
Treatment Options for Hiatus Hernia and GERD
- Proton pump inhibitors (PPIs) are commonly used to treat GERD and can be effective in relieving symptoms of hiatal hernia 3, 5, 4.
- Lifestyle changes, such as weight loss and smoking cessation, can also be useful in managing GERD symptoms 4.
- Surgery, such as laparoscopic fundoplication, may be an option for select patients with hiatal hernia and GERD 4.
- Concomitant administration of a histamine2 receptor antagonist and a PPI can enhance gastric acid suppression 6.