What is the treatment for hiatal hernia?

From the Guidelines

Treatment for hiatal hernia should prioritize a personalized approach, starting with lifestyle modifications and medications, and progressing to surgical options like laparoscopic fundoplication, magnetic sphincter augmentation, or transoral incisionless fundoplication in carefully selected patients, as recommended by the most recent guidelines 1.

Initial Management

Initial management of hiatal hernia includes:

• Weight loss if overweight
• Avoiding large meals
• Not lying down for 3 hours after eating
• Elevating the head of the bed by 6-8 inches
• Avoiding trigger foods like spicy or fatty items, chocolate, caffeine, and alcohol Medications commonly prescribed include:
• Proton pump inhibitors (PPIs) such as omeprazole (20-40mg daily) or pantoprazole (40mg daily)
• H2 blockers like famotidine (20mg twice daily)
• Antacids for immediate symptom relief These medications reduce stomach acid production, helping alleviate symptoms like heartburn and regurgitation.

Surgical Options

For persistent symptoms despite conservative treatment, surgical options include:

• Laparoscopic Nissen fundoplication, which wraps the upper part of the stomach around the lower esophagus to strengthen the sphincter
• Magnetic sphincter augmentation
• Transoral incisionless fundoplication, an effective endoscopic option in carefully selected patients 1 Surgery is typically reserved for patients with large hernias, severe symptoms unresponsive to medication, or complications like strangulation. The treatment approach targets the underlying mechanism of hiatal hernia, where part of the stomach pushes through the diaphragm into the chest, causing acid reflux and associated symptoms. According to recent studies, laparoscopic fundoplication and magnetic sphincter augmentation are effective surgical options, and transoral incisionless fundoplication is an effective endoscopic option in carefully selected patients 1. In cases of complicated diaphragmatic hernia, a minimally invasive abdominal approach can be performed with an excellent safety profile, and fundoplication should be considered to manage associated gastroesophageal reflux 1.

From the FDA Drug Label

Omeprazole delayed-release capsules are used in adults: • for up to 8 weeks for the healing of duodenal ulcers • with certain antibiotics for 10 to 14 days to treat an infection caused by bacteria called H. pylori. • for up to 8 weeks for healing stomach ulcers. • for up to 4 weeks to treat heartburn and other symptoms that happen with gastroesophageal reflux disease (GERD). • for up to 8 weeks to heal acid-related damage to the lining of the esophagus (called erosive esophagitis or EE).

The treatment for hiatal hernia is not directly mentioned in the provided drug labels. However, gastroesophageal reflux disease (GERD), which can be associated with hiatal hernia, is mentioned as an indication for omeprazole delayed-release capsules.

• The recommended dosage for GERD is 20 mg once daily for up to 4 weeks.
• For erosive esophagitis (EE) due to acid-mediated GERD, the recommended dosage is 20 mg once daily for 4 to 8 weeks. It is essential to consult a doctor for proper diagnosis and treatment of hiatal hernia, as the treatment may involve lifestyle modifications, medications, or surgery, depending on the severity of the condition 2 2.

From the Research

Treatment Options for Hiatal Hernia

The treatment for hiatal hernia can vary depending on the severity of the condition and the presence of symptoms. Some of the treatment options include:

• Watchful waiting for asymptomatic hiatal hernias 3
• Operative repair with an anti-reflux procedure for symptomatic hiatal hernias and those with confirmed reflux disease 3
• Transoral incisionless fundoplication (TIF) for patients with hiatal hernias > 2 cm and gastroesophageal reflux disease (GERD) 4, 5
• Laparoscopic Nissen fundoplication (LNF) for patients with GERD and moderate hiatal hernia (2-5 cm) 4
• Concomitant hiatal hernia repair with TIF (cTIF) for patients with refractory GERD and hiatal hernias > 2 cm 5

Surgical Procedures

Surgical procedures for hiatal hernia repair may involve:

• Reduction and excision of hernia sac
• Crural closure with mesh reinforcement
• Anti-reflux procedure
• Gastropexy and gastrostomy placement as an alternative procedure 3
• Laparoscopy and oesophagectomy procedures 6

Medical Management

Medical management of hiatal hernia may involve:

• Proton pump inhibitors (PPIs) to mitigate gastric reflux disease 7, 6
• Antacids and histamine-2-receptor blockers to reduce symptoms 6
• However, PPI use may delay proper workup to identify recurrent hiatal hernia and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms 7