Referral for Hiatal Hernia
Patients with hiatal hernia should be referred to a gastroenterologist for initial evaluation and management, with surgical referral to a general or thoracic surgeon reserved for those with refractory symptoms despite optimal medical therapy, large paraesophageal hernias, or complications.
Initial Referral Pathway
Gastroenterology Referral
- Refer to gastroenterology for diagnostic confirmation and medical management when patients present with typical GERD symptoms (heartburn, regurgitation, dysphagia) or suspected hiatal hernia on imaging 1, 2.
- Gastroenterologists perform essential diagnostic procedures including upper endoscopy to evaluate for esophagitis, strictures, and Barrett's esophagus 3.
- They initiate first-line medical therapy with proton pump inhibitors (PPIs) administered 30-60 minutes before meals 1.
- High-resolution manometry and 24-hour pH-impedance monitoring are ordered by gastroenterologists to evaluate esophageal function and confirm refractory GERD before surgical consideration 1.
Radiology for Diagnostic Imaging
- A biphasic esophagram or double-contrast upper GI series should be ordered as the initial imaging test, with 80% sensitivity for detecting associated esophagitis 2, 3.
- CT scan is reserved for complicated cases or when clinical suspicion remains high despite inconclusive initial studies, serving as the gold standard for complicated diaphragmatic hernias with 87% specificity 4, 2.
Surgical Referral Criteria
When to Refer to General/Thoracic Surgery
- Refer to surgery when GERD remains refractory to optimized medical treatment or when persistent obstructive symptoms occur 1.
- Immediate surgical referral is warranted for large paraesophageal hernias (Type II, III, or IV) due to risk of incarceration and volvulus, even if asymptomatic 5, 6.
- Patients with confirmed complications including gastric volvulus, ischemia, or incarceration require urgent surgical consultation 4, 6.
- Symptomatic hiatal hernias with confirmed reflux disease documented by pH monitoring require operative repair with anti-reflux procedure 5, 7.
Asymptomatic Hernias
- Watchful waiting with gastroenterology follow-up is appropriate for asymptomatic hiatal hernias, as they become symptomatic at only 1% per year 5.
- Select asymptomatic patients with large paraesophageal hernias may be offered elective surgical repair after shared decision-making discussion 7.
Important Caveats
Preoperative Requirements
- All patients considered for antireflux surgery must undergo barium esophagogram to evaluate hernia type, size, and esophageal anatomy 1, 2.
- High-resolution manometry is mandatory to evaluate esophageal peristaltic function and rule out achalasia before any surgical intervention 1.
- Distinguishing between sliding hernias (Type I, 90% of cases) and paraesophageal hernias is crucial as surgical approaches differ significantly 2, 3.
Common Pitfalls to Avoid
- Do not delay surgical referral for large paraesophageal hernias even if minimally symptomatic, as emergency surgery carries higher morbidity than elective repair 6.
- Avoid relying solely on chest X-ray, as 11-62% of diaphragmatic hernias show normal radiographs 2.
- Do not proceed to surgery without proper preoperative physiological testing (manometry and pH monitoring) to confirm diagnosis and rule out alternative pathology 1.