What are the guidelines for managing a patient with a hiatal hernia and severe Gastroesophageal Reflux Disease (GERD) symptoms?

Management of Hiatal Hernia with Severe GERD

For patients with hiatal hernia and severe GERD symptoms, initiate a 4-8 week trial of once-daily PPI therapy (20 mg omeprazole before breakfast), escalate to twice-daily dosing if symptoms persist, and if medical therapy fails after objective confirmation of GERD, proceed to laparoscopic fundoplication with crural repair or magnetic sphincter augmentation as definitive treatment. 1

Initial Medical Management

PPI Therapy Protocol

• Start with omeprazole 20 mg once daily taken 30 minutes before the first meal for 4-8 weeks 1, 2
• If inadequate response after 4-8 weeks, escalate to twice-daily dosing (before breakfast and dinner) rather than adding H2-receptor antagonists 1, 3
• Do not combine PPIs with H2RAs—this combination provides no additional benefit and H2RAs develop tachyphylaxis within days 3, 4

Adjunctive Therapy

• Alginate antacids (e.g., Gaviscon) for breakthrough symptoms, particularly after meals and at bedtime, as they neutralize the postprandial acid pocket and displace it below the diaphragm in patients with large hiatal hernias 1, 3
• Lifestyle modifications: elevate head of bed 6-8 inches, avoid meals within 3 hours of bedtime, eliminate coffee, alcohol, chocolate, peppermint, and spicy foods 1, 4

Diagnostic Evaluation for PPI-Refractory Symptoms

Endoscopic Assessment

Complete endoscopic evaluation must include: 1

• Grading of erosive esophagitis (Los Angeles classification)
• Assessment of diaphragmatic hiatus (Hill grade of flap valve)
• Measurement of axial hiatal hernia length—critical for surgical planning
• Inspection and biopsy for Barrett's esophagus (Prague classification)

Objective Reflux Testing

• If endoscopy shows Los Angeles grade B or higher esophagitis or long-segment Barrett's (≥3 cm), GERD is confirmed and long-term management is required 1, 4
• If endoscopy is normal or shows only mild disease, perform 96-hour wireless pH monitoring off PPI therapy to confirm pathologic acid exposure 1, 4
• For patients already on twice-daily PPIs with persistent symptoms, consider 24-hour pH-impedance monitoring on PPI to determine mechanism (acid reflux vs. non-acid reflux vs. reflux hypersensitivity) 1

Critical pitfall: Up to 60% of PPI-refractory patients have functional heartburn or reflux hypersensitivity rather than true acid-mediated GERD, requiring neuromodulation or behavioral therapy instead of surgery 3, 4

Surgical Management

Candidacy Requirements

Before proceeding to surgery, confirm: 1

• Objective evidence of pathologic GERD (endoscopy or pH monitoring)
• Exclusion of achalasia
• Assessment of esophageal peristaltic function (high-resolution manometry)

Surgical Options for Non-Obese Patients

Laparoscopic fundoplication with crural repair is the primary surgical option for hiatal hernia with severe GERD 1

• Nissen fundoplication (360-degree wrap) for patients with normal esophageal motility 1, 5
• Partial fundoplication (Toupet or Dor) preferred in patients with esophageal hypomotility or impaired peristaltic reserve to reduce postoperative dysphagia risk 1
• A randomized trial demonstrated that hiatal hernia repair with fundoplication significantly reduced DeMeester scores, reflux episodes, and symptom scores compared to hernia repair alone at 2-year follow-up 5

Magnetic sphincter augmentation (MSA) combined with crural repair is an effective alternative, particularly for patients concerned about gas-bloat syndrome 1, 6

• MSA achieves comparable GERD relief to Nissen fundoplication without the negative side effects of inability to belch or vomit 6

Transoral incisionless fundoplication (TIF) is an endoscopic option but only for carefully selected patients without hiatal hernia or with hernias ≤2 cm 1

• For hernias >2 cm, concomitant laparoscopic hiatal hernia repair with TIF (cTIF) shows promising results with 73.8% PPI discontinuation rates and low complication rates (4.4%), though long-term data are limited 7, 8

Surgical Options for Obese Patients

Roux-en-Y gastric bypass is the primary anti-reflux intervention in obese patients with proven GERD 1

• Avoid sleeve gastrectomy as it has potential to worsen GERD 1

Long-Term Management

• Patients with erosive esophagitis (LA grade B or higher) or Barrett's esophagus require indefinite PPI therapy if not pursuing surgical intervention 3, 4
• For patients on long-term PPIs without objective GERD confirmation, re-evaluate appropriateness and dosing within 12 months and offer endoscopy with prolonged wireless reflux monitoring off PPI 1
• After successful surgery, the LOTUS trial showed 85% remission rates at 5 years with fundoplication, though this was not significantly different from optimized medical therapy after accounting for dropouts 1

Common Pitfalls to Avoid

• Do not empirically rotate between different PPIs—this has low yield and delays correct diagnosis 4
• Do not assume GERD is confirmed based solely on symptom improvement with PPIs—this may be placebo effect 4
• Do not perform surgery without objective confirmation of pathologic GERD—functional disorders require neuromodulation, not fundoplication 1, 4
• Do not continue escalating acid suppression indefinitely in PPI non-responders without diagnostic evaluation 1, 3