Initial Management and Treatment for Hiatal Hernia
The initial management of hiatal hernia should begin with lifestyle modifications and acid suppression therapy with proton pump inhibitors (PPIs), with surgery reserved for patients with complicated hernias or those who fail medical management. 1, 2
Diagnosis and Assessment
- A double-contrast upper GI series is the most useful initial test for diagnosing a hiatal hernia, providing anatomic and functional information on esophageal length, strictures, presence of gastroesophageal reflux, and reflux esophagitis 3
- In patients with suspected hiatal hernia presenting with epigastric pain, fluoroscopy biphasic esophagram, single-contrast esophagram, or upper GI series are all appropriate initial imaging options 3
- CT scan is considered the gold standard for diagnosing diaphragmatic hernias with a sensitivity of 14-82% and specificity of 87%, particularly useful for determining the presence, location, and size of the defect 3
- Endoscopy is warranted in cases of PPI non-response, presence of alarm symptoms, isolated extra-esophageal symptoms, or in patients who meet criteria for Barrett's esophagus screening 3
Medical Management (First-Line)
Lifestyle modifications are the cornerstone of initial management and include:
Pharmacological therapy:
- A 4-8 week trial of single-dose PPI is appropriate for patients with typical reflux symptoms and no alarm symptoms 3
- Escalation to twice-daily dosing or switching to a more potent acid suppressive agent if symptoms persist 3
- Adjunctive therapy may include antiácidos with alginate, H2-receptor antagonists, baclofen, and prokinetics in cases of coexisting gastroparesis 1
When long-term PPI therapy is planned, objective reflux testing should be offered to establish a diagnosis of GERD and develop a long-term management plan 3
Surgical Management (For Complicated or Refractory Cases)
Surgery is recommended for:
Surgical approach:
- Laparoscopic approach is preferred in stable patients due to lower morbidity (5-6%) compared to open approach (17-18%) 1, 4
- Key operative steps include: reduction and excision of hernia sac, ensuring 3 cm of intraabdominal esophageal length, crural closure with mesh reinforcement, and an anti-reflux procedure 2
- For defects larger than 8 cm or an area greater than 20 cm², mesh should be used with the mesh overlapping the defect edge by 1.5-2.5 cm 3, 1
Anti-reflux procedures:
- Laparoscopic fundoplication is often utilized in non-obese patients 3
- Type of fundoplication may be tailored, with partial fundoplication preferred in patients with known esophageal hypomotility 3
- Magnetic sphincter augmentation is another option, often combined with a crural repair in the setting of known hiatal hernia 3
- Transoral incisionless fundoplication can be considered for carefully selected patients without a hiatal hernia 3
Special Considerations
- In obese patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention, while sleeve gastrectomy may worsen GERD 3
- In high-risk elderly patients unsuitable for definitive surgical repair, PEG or combined PEG/laparoscopy can be considered as they are successful in relieving symptoms, preventing recurrence, and stopping progression of complications 3
- Candidacy for invasive antireflux procedures should include confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristaltic function 3
Monitoring and Follow-up
- Patients should receive education on GERD pathophysiology and lifestyle modifications 3
- Symptom response to PPI should prompt titration to the lowest effective dose 3
- For patients with persistent symptoms despite optimized therapy, additional testing including high-resolution manometry and gastric emptying studies may be warranted 3