How should a patient with a hiatus hernia be evaluated and managed, including indications for medical therapy versus surgical referral?

Hiatus Hernia: Evaluation and Management

Initial Assessment and Diagnosis

Most hiatus hernias are asymptomatic sliding hernias that require no treatment; however, symptomatic patients need evaluation for gastroesophageal reflux disease (GERD) and consideration for objective diagnostic testing before long-term therapy. 1, 2

Clinical Presentation

• Asymptomatic sliding hiatus hernias discovered incidentally on imaging do not require endoscopy or treatment. 1 Only 4.5% of physicians would request endoscopy for an asymptomatic sliding hiatus hernia seen on barium meal. 1

• Symptomatic patients typically present with heartburn, regurgitation, dysphagia, or epigastric pain—symptoms that overlap with GERD. 3, 4, 5

• Larger hiatus hernias are more likely to cause dysphagia and are associated with increased severity of reflux esophagitis, Barrett's esophagus, and reduced efficacy of proton pump inhibitor therapy. 4, 5

Diagnostic Imaging

• For suspected hiatus hernia with clinical symptoms, fluoroscopy biphasic esophagram, single-contrast esophagram, or upper GI series are all appropriate initial imaging modalities. 1 These are equivalent alternatives for detecting hernia presence, size, esophageal length, strictures, and reflux. 1

• Double-contrast upper GI series is the most useful fluoroscopic test for diagnosing hiatus hernia and provides anatomic and functional information including hernia size and subtype. 1

Medical Management

Initial Therapy

• Initiate a 4–8 week trial of once-daily proton pump inhibitor (PPI) taken 30–60 minutes before the first meal, combined with lifestyle modifications including weight management, head-of-bed elevation, avoiding meals 3 hours before bedtime, tobacco cessation, and alcohol avoidance. 6, 2

• Mild or moderate reflux symptoms that respond to simple measures such as lifestyle changes, antacids, and alginates do not require endoscopy. 1

Treatment Escalation

• If symptoms persist after 4–8 weeks of once-daily PPI, escalate to twice-daily PPI therapy before the first and evening meals. 2

• Do not continue empiric PPI therapy beyond 4–8 weeks of optimized twice-daily dosing without objective testing. 2 This approach is low yield and delays appropriate diagnosis. 2

Indications for Specialist Referral

Alarm Symptoms (Immediate Referral)

• Refer immediately for dysphagia, gastrointestinal bleeding, anemia, significant weight loss, or recurrent vomiting. 2 These alarm symptoms require urgent evaluation to exclude malignancy or complications. 2

• Food bolus obstruction requires urgent same-day or emergency endoscopy. 2

Treatment Failure

• Refer to gastroenterology after 4–8 weeks of twice-daily PPI therapy without adequate symptom response. 2 Multimodality evaluation changes the diagnosis in 34.5% of PPI-refractory cases and guides alternative therapies in 42% of patients. 2

• Patients with symptoms that recur immediately upon medication discontinuation despite lifestyle modifications should be referred. 2

High-Risk Patients for Barrett's Esophagus/Adenocarcinoma

• Men older than 50 years with chronic GERD symptoms (>5 years) plus additional risk factors—including nocturnal reflux, hiatal hernia, elevated BMI, tobacco use, or intra-abdominal fat distribution—should be referred for Barrett's screening. 2

Post-Treatment Assessment

• Patients with severe erosive esophagitis after a 2-month PPI course require referral to assess healing and rule out Barrett's esophagus. 2

• Patients with a history of esophageal stricture who develop recurrent dysphagia need specialist evaluation. 2

Objective Diagnostic Testing (Performed by Specialist)

Upper Endoscopy Indications

• Perform upper endoscopy to grade erosive esophagitis using the Los Angeles classification (Grade B or higher confirms erosive GERD), measure axial hiatal hernia length in centimeters, assess for Barrett's esophagus with the Prague classification, and obtain at least 5 esophageal mucosal biopsies from multiple levels to exclude eosinophilic esophagitis. 6, 2

• Hill Grade 3 (defective flap valve that barely closes around the endoscope) reflects compromised anti-reflux barrier integrity but does not mandate immediate surgical intervention without confirming pathologic GERD. 6

pH Monitoring

• When endoscopy does not reveal Los Angeles Grade B+ esophagitis or long-segment Barrett's (≥3 cm), conduct 96-hour wireless pH monitoring off PPI therapy; pathologic acid exposure is defined as acid exposure time (AET) ≥6% on two or more days. 6

• If symptoms persist despite optimized medical therapy, consider 24-hour pH-impedance monitoring while on PPI to differentiate reflux-related mechanisms from reflux hypersensitivity, rumination, or belching disorders. 6

Esophageal Manometry

• Perform high-resolution manometry to exclude achalasia and assess esophageal peristaltic function before considering any invasive interventions. 6, 2

Surgical Candidacy and Options

Criteria for Surgery

• Candidates for anti-reflux surgery must have objective evidence of pathologic GERD (Los Angeles Grade B+ erosive esophagitis, long-segment Barrett's esophagus, or AET ≥6%), exclusion of achalasia on high-resolution manometry, and assessment of esophageal peristaltic function. 6

• Do not proceed directly to surgery based solely on endoscopic findings (such as Hill Grade 3) without confirming pathologic GERD through objective testing. 6

Surgical Approaches

• Preferred surgical options include laparoscopic fundoplication (partial fundoplication favored when esophageal hypomotility is present), magnetic sphincter augmentation combined with crural repair, or transoral incisionless fundoplication for carefully selected patients without large hiatal hernia. 6

• For obese patients with confirmed GERD, Roux-en-Y gastric bypass serves as an effective primary anti-reflux intervention. 6

• Paraesophageal hernias with organoaxial volvulus should undergo surgical repair when diagnosed due to risk of closed-loop obstruction and bleeding. 3, 7 These represent advanced degrees of sliding hernia with intrathoracic displacement and often have acquired short esophagus requiring gastroplasty. 7

Critical Pitfalls to Avoid

• Do not perform endoscopy for uncomplicated heartburn responding to treatment or for asymptomatic hiatus hernia. 1 This leads to unnecessary costs and potential complications. 2

• Do not continue long-term PPI therapy without objective confirmation of GERD; reassess the need for PPI within 12 months and consider endoscopy with prolonged off-PPI wireless pH monitoring. 6

• Do not assume all extraesophageal symptoms (cough, laryngitis) are due to GERD without proper evaluation. 2 These symptoms are often multifactorial and require upfront objective testing rather than empiric PPI trials. 2

• In children with persistent typical GERD symptoms despite PPI therapy, perform endoscopy with esophageal biopsies to exclude eosinophilic esophagitis, as 70% of pediatric EoE patients have failed PPI treatment. 2

Adjunctive Strategies for Refractory Symptoms

• Low-dose tricyclic antidepressants may be employed for patients with reflux hypersensitivity or functional overlay when standard anti-reflux therapy is insufficient. 6

• Referral to behavioral therapy (cognitive-behavioral therapy, esophageal-directed hypnotherapy, or diaphragmatic breathing exercises) is recommended for patients with inadequate response to medical therapy or with esophageal hypervigilance. 6