From the Guidelines
The best management approach for a post-stroke hemiplegic patient with a large hiatal hernia and chronic cough is to initiate a multidisciplinary strategy that addresses both conditions while considering the patient's mobility limitations, starting with empiric medical antireflux therapy and lifestyle modifications, as recommended by the ACCP guidelines 1. This approach should include:
- Optimizing hiatal hernia treatment with proton pump inhibitors such as omeprazole 20-40mg daily or pantoprazole 40mg daily to reduce acid reflux that may be exacerbating the cough.
- Positioning interventions, maintaining the patient at a 30-45 degree angle during rest and for at least 2-3 hours after meals to minimize reflux.
- Dietary modifications, including smaller, more frequent meals, avoiding trigger foods (spicy, acidic, fatty), and not eating within 3 hours of bedtime.
- Identifying the primary cause of the chronic cough, whether due to reflux, post-stroke aspiration risk, or another cause, and tailoring the treatment approach accordingly.
- Incorporating physical therapy to improve mobility, prevent complications of hemiplegia, and potentially help with diaphragmatic strengthening.
- Considering surgical repair of the hiatal hernia in severe cases where conservative management fails, while carefully evaluating stroke-related comorbidities and anesthesia risks.
- Regular monitoring for aspiration pneumonia, given the increased risk due to potential reflux and post-stroke swallowing difficulties, as supported by studies 1.
From the Research
Management Approach for Post-Stroke Hemiplegic Patient with Large Hiatal Hernia and Chronic Cough
- The management of a post-stroke hemiplegic patient with a large hiatal hernia and chronic cough requires a comprehensive approach, considering the patient's complex medical condition 2.
- For the treatment of gastroesophageal reflux disease (GERD) symptoms, proton pump inhibitors (PPIs) are often used, but their use may mask the need for revisional surgery in patients with recurrent hiatal hernia 3.
- In patients with reflux esophagitis, PPIs are considered the first-line therapeutic drug, while histamine H2 receptor antagonists (H2RAs) are used as a supplementary drug for patients with nocturnal refluxes 4.
- A study comparing the efficacy of short-term use of PPIs, H2RAs, and prokinetics in adults with GERD found that PPIs are more effective than H2RAs in relieving heartburn in patients with GERD who are treated empirically and in those with endoscopy negative reflux disease (ENRD) 5.
- For patients with GERD and persistent symptoms on PPIs, expert gastroenterologists recommend invasive therapy only in the presence of abnormal reflux burden, with or without hiatal hernia, or regurgitation with positive symptom-reflux association and a large hiatus hernia 6.
Considerations for Hemiplegic Patients
- Hemiplegic shoulder pain (HSP) is a common condition in patients with hemiplegia, and its management is challenging due to the multifactorial causes and limited evidence in support of most treatments 2.
- The approach to diagnosis and management of HSP should be based on the best available evidence to aid practitioners in obtaining optimal results 2.
- In the context of a post-stroke hemiplegic patient with a large hiatal hernia and chronic cough, the management approach should consider the patient's overall medical condition, including the presence of HSP, and develop a comprehensive treatment plan accordingly.
Treatment Options
- PPIs may be considered as a treatment option for GERD symptoms, but their use should be carefully monitored to avoid masking the need for revisional surgery in patients with recurrent hiatal hernia 3.
- Other treatment options, such as H2RAs, prokinetics, and invasive therapies, may be considered based on the patient's specific condition and the presence of abnormal reflux burden or regurgitation with positive symptom-reflux association 4, 5, 6.