Treatment of Hiatal Hernia with Nausea, Vomiting, Diarrhea, and Fever
For patients with suspected hiatal hernia presenting with nausea, vomiting, diarrhea, and fever, immediate diagnostic workup and surgical exploration are strongly recommended due to the high risk of serious complications.
Initial Assessment and Risk Stratification
The constellation of symptoms (nausea, vomiting, diarrhea, and fever) in a patient with suspected hiatal hernia requires urgent evaluation as these represent warning signs of potential complications:
Alarming clinical signs requiring immediate attention 1:
- Fever ≥ 38°C
- Tachycardia ≥ 110 beats per minute
- Persistent abdominal pain
- Respiratory distress with tachypnea and hypoxia
Risk assessment should focus on:
- Duration and severity of symptoms
- Presence of dehydration
- Signs of sepsis or peritonitis
- History of bariatric surgery (increases risk of complications)
Diagnostic Approach
Laboratory evaluation:
- Complete blood count
- C-reactive protein and procalcitonin
- Serum electrolytes
- Renal and liver function tests
- Blood gas analysis
- Serum lactate levels
Imaging studies:
- CT scan with contrast (preferred initial imaging)
- Upper GI contrast studies to evaluate hernia size and potential complications
- Chest X-ray to assess for pulmonary complications
Additional testing:
- Stool studies to rule out infectious causes
- Blood cultures if sepsis is suspected
Treatment Algorithm
1. Immediate Management
- Intravenous fluid resuscitation to correct dehydration
- Broad-spectrum antibiotics (e.g., fluoroquinolones) if infection is suspected 1
- NPO (nothing by mouth) status
- Nasogastric tube placement for decompression if vomiting is severe
2. Definitive Management
Surgical intervention is indicated for patients with:
- Persistent symptoms despite medical management
- Signs of incarceration or strangulation
- Large hiatal hernia with obstructive symptoms
- Fever and tachycardia suggesting complicated hiatal hernia 1
Surgical approach:
- Laparoscopic approach is preferred when available 2
- Complete reduction of hernia sac
- Adequate mobilization of distal esophagus
- Crural repair with non-absorbable sutures
- Anti-reflux procedure (fundoplication) when appropriate
3. Special Considerations
- Post-bariatric surgery patients require particular attention as hiatal hernias may present with atypical symptoms and higher complication rates 3
- For patients with history of sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass with concurrent hiatal hernia repair is strongly indicated 2
Medical Management
For patients with uncomplicated hiatal hernia after acute symptoms resolve:
Proton pump inhibitors (e.g., lansoprazole) for GERD symptoms 4
Lifestyle modifications:
- Weight management
- Elevation of head of bed
- Avoidance of meals 2-3 hours before bedtime
- Elimination of trigger foods
Adjunctive therapies for ongoing symptoms 1:
- Alginate antacids for breakthrough symptoms
- H2-receptor antagonists for nocturnal symptoms
- Prokinetics if gastroparesis is present
Monitoring and Follow-up
- Close monitoring for 24-48 hours after initial treatment
- Surgical follow-up within 1-2 weeks if surgery was performed
- Endoscopic surveillance if Barrett's esophagus is present
Complications and Pitfalls
- Delayed diagnosis can lead to strangulation, ischemia, and perforation
- Misdiagnosis as simple gastroenteritis may occur without proper imaging
- Post-surgical complications include dysphagia, gas-bloat syndrome, and recurrence
- Large hiatal hernias (>5cm) are associated with more severe esophagitis and higher rates of Barrett's esophagus 5
Remember that the presence of fever and gastrointestinal symptoms in a patient with hiatal hernia should never be dismissed as they may indicate serious complications requiring urgent intervention.