What is the diagnostic workup and treatment for a patient presenting with symptoms of a hiatal hernia?

Diagnostic Workup and Treatment for Hiatal Hernia

The diagnostic workup for hiatal hernia should begin with chest radiography as the first-line imaging, followed by upper endoscopy for definitive diagnosis, with treatment decisions based on symptom severity, hernia type, and complications. 1

Clinical Presentation and Initial Assessment

Hiatal hernias are classified into four types:

• Type I (sliding): Most common (90% of cases)
• Type II (paraesophageal)
• Type III (combined)
• Type IV (complex)

Common Symptoms

• Gastroesophageal reflux symptoms (heartburn, regurgitation)
• Dysphagia
• Epigastric or chest pain
• In severe cases: volvulus or incarceration symptoms

Physical Examination

• Look for signs of complications (rare but serious)
• Assess for other contributing factors like obesity

Diagnostic Workup

First-Line Imaging

• Chest radiography: Recommended as initial imaging by the American College of Radiology 1
  • Sensitivity varies: 2-60% for left-sided, 17-33% for right-sided hernias
  • May show air-fluid level or abnormal gastric shadow above the diaphragm

Second-Line Investigations

1. Upper endoscopy (EGD):

   • Superior to barium swallow with 97.5% diagnostic accuracy 2
   • Allows direct visualization of the hernia and assessment of mucosal damage
   • Can identify complications like esophagitis, Barrett's esophagus, or strictures

2. CT scan with IV contrast:

   • Sensitivity: 14-82%, Specificity: 87% 1
   • Particularly useful for paraesophageal hernias or when complications are suspected
   • Should be performed with neutral oral contrast (water or dilute barium) 3

3. Upper GI series (barium swallow):

   • Helpful for evaluating structural and functional abnormalities 3
   • May be omitted if endoscopy is performed, as it provides limited additional information 2

4. Esophageal manometry:

   • Not required for diagnosis but helpful for surgical planning
   • Assesses esophageal motility to determine appropriate fundoplication technique

5. pH monitoring:

   • Indicated when GERD symptoms are present without endoscopic evidence
   • Helps determine if acid suppression therapy is needed

Treatment Approach

Conservative Management

• Appropriate for asymptomatic or mildly symptomatic hernias 4
• Medical therapy:
  • Proton pump inhibitors (PPIs): 4-8 week trial recommended before considering surgery 1
  • Lifestyle modifications: weight loss, avoiding large meals, elevation of head of bed

Surgical Indications

• Symptomatic hiatal hernias with failed medical management
• Paraesophageal hernias (higher risk of complications)
• Complications: obstruction, volvulus, bleeding, or severe symptoms

Surgical Approach

• Laparoscopic repair: Standard approach with lower morbidity 5

  • Key steps include:
    1. Reduction and excision of hernia sac
    2. Ensuring 3 cm of intra-abdominal esophageal length
    3. Crural closure (with mesh reinforcement for large defects)
    4. Anti-reflux procedure (fundoplication) 4

• Type of fundoplication:

  • Nissen (360° wrap): Most common
  • Toupet (270° posterior wrap): May have lower recurrence rates
  • Choice should be based on esophageal motility 1

Post-Surgical Considerations

• Continue PPI therapy in patients with Barrett's esophagus 1
• Surveillance endoscopy for Barrett's esophagus:
  • Every 3-5 years for non-dysplastic Barrett's
  • More frequent for Barrett's with dysplasia 1

Complications and Pitfalls

• Recurrence: Occurs in 3-5% of cases 1

  • More common with large hernias or inadequate repair
  • May require reoperation with thorough preoperative workup 6

• Missed diagnosis of short esophagus: May require Collis gastroplasty 1

• Post-operative complications:

  • Dysphagia (most common)
  • Gas-bloat syndrome
  • Surgical site infections
  • Mesh-related complications

Special Considerations

• Asymptomatic paraesophageal hernias: Watchful waiting is appropriate, with surgical intervention at a rate of approximately 1% per year 4

• Elderly or high-risk patients: Consider risk-benefit ratio of surgical intervention

  • Gastropexy with gastrostomy may be an alternative when standard repair is not feasible 4