Hernia Belts Are Not Recommended for Hiatal Hernias
A hernia belt has no role in the management of hiatal (paraesophageal) hernias and will not address the underlying pathology causing this patient's severe epigastric pain and GERD. External compression devices are designed for abdominal wall hernias (inguinal, umbilical, incisional), not intrathoracic herniation of stomach through the diaphragm.
Why Hernia Belts Are Ineffective for Hiatal Hernias
Hiatal hernias involve herniation of the stomach through the esophageal hiatus into the thoracic cavity, making external abdominal compression mechanically irrelevant and unable to reduce the hernia or prevent complications 1.
The pathophysiology involves diaphragmatic defects and incompetence of the gastroesophageal junction, which cannot be addressed by external pressure 2.
Surgery is the treatment of choice for complicated non-traumatic diaphragmatic hernias, particularly when patients have severe symptoms like this patient's frequent severe epigastric pain 1.
Appropriate Management for This Patient
Immediate Diagnostic Workup Required
This 72-year-old woman with frequent and severe epigastric pain requires urgent evaluation to exclude complications such as gastric volvulus, ischemia, or incarceration, which carry significant morbidity and mortality risk 1, 3.
Contrast-enhanced CT of chest and abdomen with both IV and oral contrast should be obtained immediately to assess for complications, as CT is the gold standard for complicated diaphragmatic hernias with 87% specificity and can identify ischemia (absent gastric wall enhancement, intestinal wall thickening) 4, 1.
If CT demonstrates signs of strangulation, ischemia, or volvulus, emergency surgical repair is indicated immediately without delay 1.
Surgical Consultation Is Warranted
Laparoscopic paraesophageal hernia repair (PEHR) is safe and effective in elderly patients, with studies showing no difference in mortality, length of stay, or complications between patients <65 years, 65-80 years, and ≥80 years 5.
Symptom improvement occurs in 78.3% of patients after PEHR, with quality-of-life benefits justifying surgical intervention even in advanced age 5.
Minimally invasive approach is suggested for stable patients with complicated non-traumatic diaphragmatic hernias, offering lower morbidity (5-6%) compared to open approach (17-18%) 1.
Medical Management While Awaiting Surgery
Continue high-dose proton pump inhibitor (PPI) therapy administered 30-60 minutes before meals to manage GERD symptoms, though this addresses only the reflux component and not the mechanical hernia problem 3.
Patients with hiatal hernia and GERD have more severe disease than those without hernia, with higher rates of severe esophagitis and reflux on objective testing 6.
Critical Pitfalls to Avoid
Do not delay surgical evaluation in elderly patients based on age alone—age is not an independent risk factor for perioperative morbidity or mortality after PEHR, and avoidance of emergent intervention is achieved through judicious elective repair 5.
Never assume severe epigastric pain is simply "reflux"—this symptom pattern suggests possible gastric volvulus or ischemia requiring urgent imaging and potential emergency surgery 1.
Do not rely on medical management alone for symptomatic hiatal hernias—surgery should be considered for patients with refractory symptoms or those who develop complications such as recurrent bleeding, ulcerations, or strictures 2.
Preoperative Requirements Before Elective Repair
If imaging excludes acute complications and elective repair is planned:
Barium esophagram (biphasic or double-contrast upper GI series) to evaluate hernia type, size, and esophageal anatomy 3, 4.
High-resolution manometry is mandatory to evaluate esophageal peristaltic function and rule out achalasia before any surgical intervention 3.
Upper endoscopy to evaluate for esophagitis, strictures, Barrett's esophagus, and rule out malignancy 3.
24-hour pH-impedance monitoring if GERD symptoms are refractory to medical therapy 3.