From the Guidelines
Medical management of hiatal hernia should primarily focus on treating symptoms, especially gastroesophageal reflux disease (GERD), with proton pump inhibitors (PPIs) as the cornerstone of treatment, as increasing the dose or switching to another PPI can benefit a subset of patients 1. The initial approach to managing hiatal hernia involves lifestyle modifications, including:
- Weight loss
- Avoiding large meals
- Not eating 2-3 hours before bedtime
- Elevating the head of the bed by 6-8 inches
- Avoiding trigger foods like caffeine, chocolate, alcohol, and spicy or fatty foods
Medication therapy typically begins with antacids for immediate but short-term relief. For persistent symptoms, H2 receptor blockers like famotidine or ranitidine can be used. However, PPIs are more effective for severe symptoms; options include omeprazole, esomeprazole, or pantoprazole, typically taken 30 minutes before breakfast 1. In addition to PPIs, other medications such as histamine-2 receptor antagonists (H2RA), alginates, and baclofen, a GABA agonist, can be used to improve control of GERD symptoms in some patients 1. If symptoms persist despite medical management, surgical intervention may be considered, with options including laparoscopic fundoplication, magnetic sphincter augmentation, and transoral incisionless fundoplication, which have demonstrable value in patients with regurgitation-predominant GERD 2. It is essential to note that the management of hiatal hernia should be personalized, taking into account the patient's specific symptoms, medical history, and response to treatment, as well as the potential risks and benefits of each treatment option 2.
From the Research
Medical Management of Hiatal Hernia
The medical management of hiatal hernia involves a combination of lifestyle modifications, medications, and surgical interventions.
- Lifestyle modifications: + Weight loss + Avoiding heavy lifting or bending + Avoiding tight clothing + Elevating the head of the bed
- Medications: + Antacids + Proton pump inhibitors (PPIs) + Histamine-2-receptor blockers
Surgical Management
Surgical management is typically reserved for symptomatic hiatal hernias or those with confirmed reflux disease.
- Key operative steps: + Reduction and excision of hernia sac + 3 cm of intraabdominal esophageal length + Crural closure with mesh reinforcement + An anti-reflux procedure
- Alternative procedures: + Gastropexy + Gastrostomy placement
Diagnosis and Treatment
The diagnosis of hiatal hernia typically involves a combination of endoscopy, radiology, manometry, and CT scanning 3.
- Treatment options: + Laparoscopy + Oesophagectomy + Minimally invasive laparoscopy
- Post-operative management: + 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 4.
Recent Updates
Recent studies have highlighted the importance of hiatal hernia repair technique on patient-reported gastroesophageal reflux symptoms following laparoscopic sleeve gastrectomy 5.
- Hiatal hernia repair techniques: + Posterior repair with mesh (PRM) + Posterior repair (PR) + Anterior repair (AR)
- Recommendations: + A posterior repair is recommended for hiatal hernia repair at the time of laparoscopic sleeve gastrectomy 5. + More randomized studies need to be done on subsets of patients, stratified by age, gender, symptoms, and comorbidities to address unanswered questions and solid updates on the guidelines 6.
Management of Hiatal Hernia
The management of hiatal hernia is a complex process that requires a comprehensive approach, including diagnosis, treatment, and post-operative management 7, 3, 6.
- Diagnostic pathway: + Endoscopy + Radiology + Manometry + CT scanning
- Treatment options: + Medical management + Surgical management + Minimally invasive laparoscopy
- Post-operative management: + PPI use + Diagnostic workup to rule out anatomic cause for recurrent symptoms 4.