From the Guidelines
Hiatal hernias should be managed based on their type and symptoms, with lifestyle modifications and medications such as proton pump inhibitors being the first line of treatment, as recommended by recent studies 1. When it comes to hiatal hernias, there are four main types, including Type I, which is the most common, and Types II, III, and IV, which are less common but can be more severe 1. For symptomatic hiatal hernias, the following lifestyle modifications are recommended:
- Weight loss if overweight
- Avoiding large meals
- Not lying down within 3 hours after eating
- Elevating the head of the bed by 6-8 inches
- Avoiding trigger foods like fatty or spicy foods, chocolate, caffeine, and alcohol Medications that can help manage symptoms include:
- Antacids (like Tums or Rolaids) for immediate relief
- H2 blockers (such as famotidine 20mg twice daily or ranitidine 150mg twice daily) for moderate symptoms
- Proton pump inhibitors (like omeprazole 20mg daily or pantoprazole 40mg daily) for more severe symptoms, as they remain the cornerstone for treatment of patients with persistent symptoms 1. Surgery may be considered for very large hernias or when symptoms persist despite medical therapy, with the most common procedure being a Nissen fundoplication, which wraps the upper part of the stomach around the lower esophagus to strengthen the barrier to reflux. It's also worth noting that adding sodium alginate to PPI can result in a significantly greater rate of complete resolution of heartburn in patients with non-erosive reflux disease (NERD), and baclofen, a GABA agonist, can be useful as an add-on therapy to PPI but is limited by side effects 1.
From the Research
Definition and Classification of Hiatal Hernia
- A hiatal hernia is described as an enlarged diaphragmatic hiatus esophageus, through which the gastroesophageal transition occurs 2.
- The most common classification distinguishes four types of hiatus hernias according to their anatomical morphological characteristics (type I-IV) 2.
Symptoms and Treatment of Hiatal Hernia
- Symptoms of hiatal hernia are related to reflux disease, but also to intrathoracic compression symptoms due to the dislodgement of intrathoracic organs into the mediastinum 2.
- Treatment recommendation is guided by patients' symptoms, as no conservative treatment of a hiatal hernia is possible 2.
- High recurrence rates after surgical treatment of a hiatal hernia and antireflux surgery led to a discussion about diaphragm closure with or without mesh augmentation, and data seem to indicate that hiatal mesh augmentation reduces recurrence 2.
Diagnosis and Management of Hiatal Hernia
- The diagnostic pathway for hiatal hernia has remained virtually unchanged, but new data have come to light regarding the surgical treatment of hiatal hernia 3.
- Imaging methods, such as gastric fiberscopy, are used for diagnosis, as well as medical and surgical treatment currently available 3.
- Proton pump inhibitors (PPIs) are commonly used to relieve symptoms of hiatal hernia, but their use may delay proper workup to identify recurrent hiatal hernia amenable to surgical repair 4.
Proton Pump Inhibitor Use and Hiatal Hernia
- PPI use is common after hiatal hernia repair, but it may mask patients who would benefit from revisional surgery 4.
- The use of PPIs in patients who have undergone hiatal hernia repair may delay proper workup to identify recurrent hiatal hernia and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms 4.
- Early postoperative use of PPIs has been shown to be effective in relieving GI symptoms and preventing upper GI disorders after cardiac surgery in patients with type I hiatal hernia 5.
Management Options for Patients with GERD and Hiatal Hernia
- Expert gastroenterologists recommend invasive therapy only in the presence of abnormal reflux burden, with or without hiatal hernia, or regurgitation with positive symptom-reflux association and a large hiatus hernia 6.
- Non-invasive pharmacologic or behavioral therapies are preferred for all other scenarios, including elevated esophageal acid exposure, transient lower esophageal sphincter relaxation, and positive symptom-reflux association 6.