From the Guidelines
For patients with hiatal hernia, the most appropriate initial diagnostic approach is a fluoroscopy biphasic esophagram or fluoroscopy upper GI series, as it provides anatomic and functional information on esophageal length, esophageal stricture, presence of gastroesophageal reflux, and reflux esophagitis 1. When evaluating a patient with a hiatal hernia, it's essential to consider the size and type of hernia, as well as the presence of symptoms such as heartburn, regurgitation, and chest pain.
Key Considerations
- Hiatal hernias can be classified into four main types: Type I (sliding hiatal hernia), Type II (paraesophageal hiatal hernia), Type III (combination of Type I and Type II), and Type IV (large diaphragmatic hernia) 1.
- The diagnostic approach should include a thorough evaluation of the esophagus and stomach to detect any complications such as reflux esophagitis, strictures, or sacculations.
- Treatment options for hiatal hernia include lifestyle changes, over-the-counter medications, and surgical repair for severe cases.
Diagnostic Approach
- A fluoroscopy biphasic esophagram or fluoroscopy upper GI series is the recommended initial diagnostic approach, as it provides valuable information on esophageal length, esophageal stricture, and presence of gastroesophageal reflux 1.
- The sensitivity of single-contrast examinations for detecting endoscopically proven esophagitis is 77%, while double-contrast examinations have a higher sensitivity of 80% 1.
Treatment Options
- Lifestyle changes, such as eating smaller meals, avoiding lying down after eating, and maintaining a healthy weight, can help manage symptoms of hiatal hernia.
- Over-the-counter medications, such as antacids, H2 blockers, or proton pump inhibitors, can help manage acid reflux symptoms.
- Surgical repair, typically through laparoscopic procedures like Nissen fundoplication, may be necessary for severe cases that don't respond to conservative treatment.
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.
- Type-I is the most frequent category, also known as sliding hiatal hernia, emanating from the right crus of the diaphragm 3.
- Type-II esophageal hernia engages both left and right muscular crura, while Type-III and IV additionally include the left crus 3.
Symptoms and Risk Factors
- 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.
- Familiar manifestations include gastric reflux, nausea, bloating, chest and epigastric discomfort, pharyngeal and esophageal expulsion, and dysphagia 3.
- Age and increased body mass index are key risk factors, and congenital skeletal aberrations trigger pathogenesis through intestinal malrotations 3.
Diagnosis and Treatment
- The diagnostic pathway for hiatal hernia has remained virtually unchanged, but new data have come to light regarding the surgical treatment 4.
- Imaging methods such as endoscopy, radiology, manometry, and CT scanning are used for diagnosis 3.
- Treatment can be challenging at times, depending on the existence of complications, and may include antacids, proton pump inhibitors, and histamine-2-receptor blockers 3.
- Surgical approaches such as laparoscopy and oesophagectomy may be necessary for severe cases, with laparoscopy entailing fewer postoperative difficulties and better visualization of hernia and related vascular damages 3.
- The use of proton pump inhibitors after hiatal hernia repair may delay proper workup to identify recurrent hiatal hernia amenable to surgical repair 5.
Management and Prevention
- The management of hiatal hernia 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.
- Re-do surgery is a valid option for symptomatic patients with recurrent hiatal hernia 2.
- Proton pump inhibitors given in the early postoperative period can relieve symptoms of hiatal hernia after open heart surgery and prevent upper GI disorders 6.