From the Guidelines
No further investigation is typically needed after endoscopic confirmation of a large hiatus hernia, as the endoscopy provides sufficient information about the anatomy and severity of the hernia, allowing for appropriate management decisions. The most recent and highest quality study, 1, published in 2022, suggests that patients with esophageal symptoms and unproven GERD, who have undergone endoscopy without finding Los Angeles B esophagitis or long segment Barrett's esophagus, may not require further investigation.
Management Decisions
The management of a large hiatus hernia usually begins with lifestyle modifications, including:
- Weight loss
- Avoiding large meals
- Not lying down after eating
- Elevating the head of the bed Medical therapy often includes proton pump inhibitors (such as omeprazole 20-40mg daily or pantoprazole 40mg daily) for 8-12 weeks initially, then as needed for symptom control, as recommended by 1. Antacids and H2 blockers like famotidine 20mg twice daily may provide additional relief.
Surgical Intervention
Surgical intervention, typically laparoscopic fundoplication, is reserved for patients with persistent symptoms despite medical therapy, complications like strictures or Barrett's esophagus, or very large hernias causing mechanical symptoms, as suggested by 1. The decision for surgery should be individualized based on symptom severity, patient's overall health, and response to conservative measures.
Additional Testing
Additional testing might only be needed if complications are suspected or if surgical intervention is being considered, in which case manometry or pH studies might be ordered to evaluate esophageal function, as recommended by 1 and 1. However, the most recent study, 1, suggests that patients with unproven GERD and incomplete response to PPI trial for 4-8 weeks may require concurrent prolonged wireless pH monitoring off PPI.
Key Considerations
- The presence of Los Angeles C or D esophagitis, bipositional reflux, extreme levels of acid exposure, and/or large hiatal hernia may indicate a more severe phenotype of GERD, as suggested by 1.
- The management of GERD should be personalized, taking into account the patient's symptoms, response to treatment, and presence of complications, as recommended by 1 and 1.
From the Research
Further Investigation for Large Hiatus Hernia
If the endoscopy confirms that the patient has a large hiatus hernia, the need for further investigation is determined by several factors, including:
- The presence of symptoms and their severity
- The size of the hernia
- The patient's overall health and risk factors for complications
Diagnostic Considerations
The following diagnostic considerations may be relevant:
- Upper gastrointestinal series (UGI) to assess the size and position of the hernia 2
- Esophageal manometry to evaluate lower esophageal sphincter function and esophageal acid clearance 2
- 24-hour pH monitoring to assess esophageal acid exposure 2
- Imaging studies, such as CT or MRI, to evaluate the hernia and surrounding structures 3
Management Options
The management of large hiatus hernia may involve:
- Surgical repair, which can be performed laparoscopically or openly 4, 5
- Medical management, including proton pump inhibitors and lifestyle modifications, for patients with mild symptoms or those who are not candidates for surgery 3
- Surveillance and monitoring for patients with asymptomatic or minimally symptomatic hernias, to assess for signs of complications or progression of the hernia 4
Key Considerations
Key considerations in the management of large hiatus hernia include:
- The risk of complications, such as gastric volvulus and stomach necrosis, which can occur in patients with large hernias 4
- The importance of individualizing treatment based on patient factors, such as age, symptoms, and comorbidities 5, 3
- The need for further research to determine the optimal management strategies for patients with large hiatus hernia, particularly in terms of surgical techniques and outcomes 4, 5, 3