What is the recommended diagnosis and management for a sliding hiatal hernia presenting with gastro‑oesophageal reflux symptoms?

Sliding Hiatal Hernia with GERD Symptoms: Diagnosis and Management

Start with a 4-8 week trial of single-dose PPI therapy taken 30-60 minutes before meals for patients presenting with typical GERD symptoms (heartburn, regurgitation) without alarm features, escalating to twice-daily dosing if inadequate response. 1, 2

Initial Diagnostic Approach

Clinical Presentation

• Sliding hiatal hernias (Type I) account for 90% of all hiatal hernias and present with GERD symptoms due to disruption of the lower esophageal sphincter and anti-reflux barrier 2, 3
• Typical symptoms include heartburn, regurgitation, and non-cardiac chest pain that warrant empirical PPI therapy before extensive testing 1

When to Pursue Diagnostic Testing

Perform diagnostic evaluation in three scenarios: 1

• Alarm symptoms present: dysphagia, weight loss, or epigastric mass requiring immediate endoscopy 1
• Inadequate response to twice-daily PPI therapy after 4-8 weeks 1
• Before considering surgical intervention to confirm pathologic GERD 1

Comprehensive Diagnostic Evaluation

Endoscopy (EGD)

Complete endoscopic evaluation must document: 1

• Los Angeles classification of erosive esophagitis (if present) 1
• Hill grade of the gastroesophageal flap valve 1
• Axial hiatal hernia length measured in centimeters 1
• Barrett's esophagus using Prague classification with biopsy if present 1

Critical pitfall: Hold PPI therapy for 2-4 weeks before endoscopy to increase diagnostic yield for esophagitis 1

Barium Esophagram

Order a biphasic esophagram or double-contrast upper GI series as essential imaging: 4, 2

• Provides 80% sensitivity for detecting associated esophagitis 4
• Superior to endoscopy for differentiating sliding from paraesophageal hernias, which is critical because surgical approaches differ significantly 2
• Assesses hernia size, esophageal length, and presence of strictures 2

Physiologic Testing (For PPI Failures or Surgical Candidates)

Perform high-resolution manometry before any surgical consideration: 1, 4, 2

• Mandatory to assess esophageal peristaltic function 1
• Rules out achalasia, which would contraindicate fundoplication 1
• Evaluates for alternative diagnoses like distal esophageal spasm 1

Perform prolonged wireless pH monitoring (96-hour preferred) off PPI therapy: 1

• Confirms pathologic GERD when endoscopy shows no erosive disease (Los Angeles B or greater) or long-segment Barrett's 1
• Establishes appropriate use of long-term PPI therapy 1

Medical Management Algorithm

First-Line Therapy

Initiate single-dose PPI 30-60 minutes before meals for 4-8 weeks: 1, 2

• Emphasize PPI safety to patients 1
• Provide standardized education on GERD mechanisms, weight management, lifestyle modifications, and brain-gut axis 1

Lifestyle Modifications

Recommend specific behavioral changes: 2

• Head of bed elevation 2
• Avoid meals within 3 hours of bedtime, particularly for nocturnal symptoms 2

Escalation Strategy for Inadequate Response

If partial or no response after 4-8 weeks: 1, 2

• Assess compliance first 1
• Increase to twice-daily PPI dosing 1
• Switch to a more effective acid suppressive agent once daily 1

Adjunctive Pharmacotherapy (Personalized to Phenotype)

Add targeted agents based on symptom pattern: 1

• Alginate antacids for breakthrough symptoms 1
• Nighttime H2 receptor antagonists for nocturnal symptoms 1
• Baclofen for regurgitation or belch-predominant symptoms 1

Long-Term Management

Taper to lowest effective PPI dose once adequate response achieved: 1

• Evaluate appropriateness and dosing within 12 months if PPI continued for unproven GERD 1
• Consider endoscopy with prolonged wireless reflux monitoring off PPI to establish need for long-term therapy 1

Surgical Referral Criteria

Indications for Surgery

Refer to surgery when: 4, 2, 5

• GERD remains refractory to optimized medical treatment 4
• Severe erosive esophagitis (Los Angeles grade C or D) despite medical therapy 5
• Persistent obstructive symptoms occur 4
• Complications develop: gastric volvulus, ischemia, or incarceration requiring urgent consultation 4

Mandatory Preoperative Requirements

All surgical candidates must undergo: 1, 4, 2

• Barium esophagram to evaluate hernia type, size, and esophageal anatomy 4
• High-resolution manometry to evaluate peristaltic function and rule out achalasia 1, 4
• 24-hour pH-impedance monitoring off PPI to confirm pathologic GERD 4
• Updated endoscopy to assess current mucosal status, particularly if Barrett's esophagus present 4

Surgical Options

Laparoscopic fundoplication is the preferred approach: 1, 2, 5

• Excellent safety profile with 0.14% in-hospital mortality 5
• Superior outcomes compared to open surgery 2
• Magnetic sphincter augmentation is an alternative effective option 1
• Transoral incisionless fundoplication available for carefully selected patients 1

Critical Pitfalls to Avoid

• Never proceed to surgery without proper physiological testing (manometry and pH monitoring) to confirm diagnosis and rule out alternative pathology 4
• Do not rely solely on chest X-ray, as 11-62% of diaphragmatic hernias show normal radiographs 4
• Avoid assuming Barrett's status is unchanged after several years—always perform updated endoscopy before surgical planning 4
• Do not perform upfront endoscopy for isolated extraesophageal symptoms—perform objective reflux testing off medication instead 1
• Never assume severe epigastric pain is simple reflux in hiatal hernia patients—may indicate gastric volvulus or ischemia requiring urgent imaging 4