What is the treatment for hiatal hernia?

Treatment for Hiatal Hernia

The treatment for hiatal hernia should be personalized based on symptom severity, with most non-severe cases managed through aggressive lifestyle modifications, PPI therapy, and adjunctive pharmacotherapy, while surgical intervention is reserved for symptomatic cases unresponsive to medical management or complicated hernias. 1

Diagnostic Approach

• Upper endoscopy to identify hiatal hernia and assess for erosive esophagitis
• Prolonged wireless pH monitoring (96-hour preferred) if symptoms don't respond to PPI or to confirm GERD 1
• High-resolution manometry to evaluate esophageal motility disorders 1, 2
• CT scan with contrast may help visualize large hernias 2

Treatment Algorithm

Step 1: Lifestyle Modifications

• Weight management (even modest weight gain increases reflux symptoms) 2
• Elevate head of bed 6-8 inches
• Avoid meals within 3 hours of bedtime 1
• Identify and avoid personal dietary triggers 2
• Diaphragmatic breathing exercises 1

Step 2: Medical Management

• For patients with reflux symptoms:

  • PPI therapy (single-dose) for 4-8 weeks, taken 30-60 minutes before meals 1
  • If inadequate response, increase to twice daily or switch to more potent PPI 1
  • When symptoms are controlled, taper to lowest effective dose 1

• Adjunctive medications:

  • Alginate-based antacids for breakthrough symptoms (particularly useful for hiatal hernia patients) 1, 2
  • H2-receptor antagonists for nighttime symptoms (limited by tachyphylaxis) 1
  • Baclofen for regurgitation or belch-predominant symptoms 1
  • Prokinetics if concurrent gastroparesis 1

Step 3: Psychological Interventions

• For patients with visceral hypersensitivity or hypervigilance:
  • Cognitive behavioral therapy (CBT)
  • Esophageal-directed hypnotherapy
  • Pharmacologic neuromodulation with low-dose antidepressants 1

Step 4: Surgical Management

• Indications for surgery:

  • Symptomatic hiatal hernias unresponsive to medical therapy 3
  • Paraesophageal hernias with risk of incarceration or volvulus 3
  • Confirmed GERD with hiatal hernia 3

• Surgical approaches:

  • Laparoscopic fundoplication with hiatal hernia repair (standard approach) 2
  • Type of fundoplication tailored to esophageal motility 2
  • Mesh reinforcement of crural closure 3
  • Ensure 3 cm of intra-abdominal esophageal length 3

Special Considerations

Long-term Management

• Patients with Los Angeles B or greater esophagitis, Barrett's esophagus, or peptic stricture require long-term PPI therapy 1
• Patients with severe GERD may need indefinite PPI therapy or anti-reflux procedure 1
• Post-surgical monitoring for recurrent symptoms, dysphagia, and weight loss 2

Asymptomatic Hiatal Hernias

• Watchful waiting is appropriate for asymptomatic hernias 3
• Rate of becoming symptomatic is approximately 1% per year 3

Common Pitfalls and Caveats

• Failure to optimize PPI dosing and timing (30-60 minutes before meals)
• Not addressing lifestyle factors, especially weight management
• Overlooking psychological factors that may amplify symptoms
• Delaying surgical referral for large paraesophageal hernias with risk of complications
• Not recognizing that most hiatal hernias are sliding type (Type I) with the gastroesophageal junction displaced above the diaphragm 4

The management approach should be guided by symptom severity, objective findings on endoscopy and pH monitoring, and patient response to therapy. Surgical intervention, while effective, should be reserved for appropriate candidates after medical management has been optimized.