What is the treatment for a patient with a hiatal hernia?

Treatment of Hiatal Hernia

Initial Management Strategy

For symptomatic hiatal hernia, treatment begins with aggressive lifestyle optimization and proton pump inhibitor (PPI) therapy, with surgical repair reserved for patients with severe GERD phenotypes, refractory symptoms despite optimized medical management, or complications. 1, 2, 3

Asymptomatic Hiatal Hernia

• Watchful waiting is appropriate for asymptomatic hiatal hernias, as they become symptomatic and require repair at a rate of only 1% per year 4
• Select asymptomatic patients with large hernias (>5 cm), significant anatomic distortion, or high-risk features may be offered elective surgical repair to prevent future complications 5

Medical Management for Symptomatic Hiatal Hernia

Lifestyle Modifications (First-Line)

• Weight reduction in obese patients is essential to reduce intra-abdominal pressure 2, 3
• Elevate the head of the bed 15-20 cm to prevent nocturnal reflux 2, 3
• Avoid large meals within 3 hours of bedtime to reduce nocturnal symptoms 2, 3
• Implement diaphragmatic breathing techniques to strengthen the anti-reflux barrier 2, 3

PPI Optimization

• Ensure proper PPI timing: 30-60 minutes before meals to maximize efficacy 1, 2, 3
• Consider dose escalation to twice-daily dosing or switching to a different PPI if inadequate response after 4-8 weeks 1, 2, 3
• Patients with erosive esophagitis grade B or higher, Barrett's esophagus, or peptic stricture require indefinite long-term PPI therapy without dose reduction 1, 2, 3
• Large hiatal hernia with severe GERD (esophagitis grade C or D, bipositional reflux, or extreme acid exposure with AET >12%) requires indefinite PPI therapy 1, 2, 3
• For patients with adequate symptom control and non-severe disease, wean to the lowest effective dose or on-demand therapy 1, 2

Adjunctive Pharmacotherapy (Personalized to Symptoms)

• Alginate-based antacids are particularly useful for breakthrough symptoms in patients with known hiatal hernia, as they neutralize the post-prandial acid pocket 1, 2, 6
• Baclofen (GABA-B agonist) is specifically effective for regurgitation-predominant or belch-predominant symptoms, though limited by CNS and GI side effects 1, 6
• H2-receptor antagonists may help with nocturnal breakthrough symptoms, but use is limited by tachyphylaxis developing within weeks 1, 2, 6
• Prokinetics have no role in GERD treatment unless concomitant gastroparesis is documented 1, 6

Surgical Management

Indications for Surgery

• Symptomatic hiatal hernia with confirmed GERD (erosive esophagitis or elevated acid exposure) refractory to optimized medical therapy 3, 4, 5
• Severe GERD phenotype with large hiatal hernia, grade C or D esophagitis, or extreme acid exposure 1, 2
• Complications including gastric volvulus, organ ischemia, or incarceration 4, 7
• Patient preference after shared decision-making in appropriate candidates 5

Surgical Technique

• Laparoscopic approach is the standard of care for stable patients, offering improved outcomes and fewer postoperative complications compared to open surgery 4, 7, 8, 5
• Key operative steps include: hernia sac reduction and excision, achieving 3 cm of intra-abdominal esophageal length, crural closure, and performing an anti-reflux procedure 4, 5
• A fundoplication should be routinely performed during hiatal hernia repair to address the underlying GERD pathophysiology 5
• For patients with impaired esophageal motility on high-resolution manometry, consider partial fundoplication instead of complete Nissen fundoplication 2, 3
• The use of mesh for crural reinforcement remains controversial with equivocal evidence; consider mesh for large defects (>8 cm or area >20 cm²) 3, 5
• Laparotomy is reserved for unstable patients with complicated hernias 3

Alternative Surgical Options

• For repairs not amenable to standard technique, gastropexy and gastrostomy placement may serve as alternative procedures 4
• Transoral incisionless fundoplication is an endoscopic option for carefully selected patients with GERD and small or no hiatal hernia 2, 6

Evaluation for Refractory Symptoms

When symptoms persist despite optimized medical therapy, perform:

• Upper endoscopy to evaluate mucosal integrity and exclude complications 2
• High-resolution manometry to assess esophageal peristaltic function and exclude achalasia or rumination syndrome 1, 2, 6
• 24-hour pH-impedance monitoring on PPI therapy to determine if ongoing acid or non-acid reflux is causing symptoms 2, 6
• Gastric emptying study if concomitant gastroparesis is suspected 2

Management of Esophageal Hypersensitivity

For patients with normal acid exposure (AET <4%) but persistent symptoms:

• These patients do not have GERD and likely have a functional esophageal disorder 1
• Wean off PPI therapy unless symptoms clearly escalate off therapy and improve with PPI (reflux hypersensitivity pattern) 1
• Consider neuromodulation with low-dose antidepressants 2, 6
• Refer for cognitive behavioral therapy, esophageal-directed hypnotherapy, or diaphragmatic breathing techniques 1, 2, 6

Common Pitfalls to Avoid

• Do not wean PPI therapy in patients with erosive esophagitis grade B or higher, Barrett's esophagus, or peptic stricture, as these require indefinite acid suppression 1, 2, 3
• Avoid empiric use of adjunctive agents without personalizing to the specific GERD phenotype and symptom pattern 1
• Do not perform surgical repair without adequate preoperative physiologic testing (manometry, pH monitoring) to confirm GERD diagnosis and assess esophageal function 2, 5
• Recognize that not all symptoms in patients with hiatal hernia are due to reflux; consider functional disorders in those with normal acid exposure 1