What is the appropriate management for a patient with a sliding hiatus hernia, potentially associated with gastroesophageal reflux disease (GERD)?

Management of Sliding Hiatus Hernia

For patients with sliding hiatus hernia, initial management should focus on medical therapy with proton pump inhibitors (PPIs) for 4-8 weeks, as most sliding hernias are associated with GERD and respond well to acid suppression, with surgical intervention reserved for those with severe erosive esophagitis (LA Grade B or higher), PPI-refractory symptoms, or complications. 1

Initial Diagnostic Approach

Barium esophagram is essential for complete evaluation of any patient with suspected hiatus hernia, as it provides superior anatomic and functional information compared to endoscopy alone and is specifically recommended by the American College of Surgeons for all patients being considered for antireflux surgery. 1

Key diagnostic elements include:

• Biphasic esophagram or upper GI series should be performed to assess hernia size, esophageal length, presence of strictures, and gastroesophageal reflux, with reported sensitivity of 88% when combining single and double-contrast techniques. 1

• Barium studies are superior to endoscopy for differentiating sliding from paraesophageal hernias, which is critical because surgical approaches differ significantly between these two types. 1

• Complete endoscopic evaluation must document the Hill grade of the gastroesophageal flap valve, axial hernia length in centimeters, presence and grade of erosive esophagitis (Los Angeles classification), and Barrett's esophagus if present. 1, 2

Medical Management Strategy

Start with single-dose PPI therapy taken 30-60 minutes before a meal for 4-8 weeks as first-line treatment for symptomatic sliding hiatus hernia without alarm features. 1, 3

• Omeprazole 20 mg once daily is an appropriate initial choice for GERD symptoms associated with sliding hernia, with treatment duration up to 4 weeks for symptomatic GERD or 4-8 weeks for erosive esophagitis. 3

• If inadequate response occurs, escalate to twice-daily dosing or switch to a more potent PPI (rabeprazole, esomeprazole, or dexlansoprazole) that is less dependent on CYP2C19 metabolism. 1

• Lifestyle modifications should include head of bed elevation and avoiding meals within 3 hours of bedtime, particularly for patients with known hiatus hernia and postprandial or nocturnal symptoms. 1

• Taper to the lowest effective PPI dose once adequate symptom control is achieved, with routine re-evaluation of treatment necessity. 1

When to Pursue Objective Testing

Patients who fail 4-8 weeks of PPI therapy or have alarm symptoms require endoscopy, and if no erosive disease (LA Grade B or higher) or long-segment Barrett's esophagus (≥3 cm) is found, perform 96-hour wireless pH monitoring off PPI to confirm pathologic GERD. 1

Critical indications for testing include:

• Evaluate appropriateness of long-term PPI therapy within 12 months of initiation in patients with unproven GERD by performing endoscopy with prolonged wireless reflux monitoring off PPI (withheld for 2-4 weeks when possible). 1

• LA Grade B or higher esophagitis or long-segment Barrett's (≥3 cm) constitutes definitive GERD evidence and eliminates the need for pH monitoring. 1, 2

• LA Grade A esophagitis alone is insufficient for GERD diagnosis, as it can be seen in healthy asymptomatic volunteers and requires pH monitoring for confirmation. 1

Surgical Intervention Criteria

Surgery should be considered for patients with proven pathologic GERD who have severe erosive esophagitis (LA Grade C or D), large hernias, or medically refractory symptoms after comprehensive preoperative evaluation. 1, 4

Preoperative Requirements

• High-resolution manometry is mandatory to assess esophageal peristaltic function and exclude achalasia before any surgical intervention. 1, 4

• Barium swallow must be performed to identify the hernia, assess for strictures, and evaluate for short esophagus. 4

• Complete endoscopic documentation of LA classification grade, Hill grade of flap valve, and precise hernia length measurement is necessary. 4, 2

Surgical Approach and Technique

Laparoscopic fundoplication is the preferred surgical approach with an excellent safety profile (in-hospital mortality 0.14%) and superior outcomes compared to open surgery. 1, 4

• Nissen fundoplication (360° wrap) remains the gold standard for durable GERD symptom relief and is the most commonly performed technique. 1, 4

• Toupet fundoplication (270° posterior wrap) is an alternative with potentially lower rates of postoperative dysphagia, though it may have higher reflux recurrence rates. 4

• Closure of the diaphragmatic hiatus with non-absorbable sutures is essential to repair the hernia defect and must be performed in conjunction with fundoplication. 4

• Magnetic sphincter augmentation and transoral incisionless fundoplication are effective alternatives in carefully selected patients with proven GERD. 1

Common Pitfalls to Avoid

• Do not rely on endoscopy alone to rule out hiatus hernia, as it has high false-negative rates (45-48%) compared to surgical findings; barium studies provide complementary information. 1, 5

• Do not assume all sliding hernias require surgery—most respond well to medical management, and surgery is reserved for specific indications including severe esophagitis, refractory symptoms, or complications. 1, 4

• Do not perform surgery without confirming pathologic GERD through objective testing (endoscopy showing LA Grade B+ or pH monitoring demonstrating abnormal acid exposure). 1

• Do not overlook acquired short esophagus in patients with massive or long-standing hernias, as this may require gastroplasty in addition to fundoplication for successful repair. 6

• Recognize that high-resolution manometry has superior specificity (95%) compared to endoscopy (68%) for ruling out hiatus hernia, though both have significant false-negative rates. 5