What is the cause of hernia in an obese middle-aged lady with symptoms of Gastroesophageal Reflux Disease (GORD), where the gastroesophageal junction is above the level of the diaphragm?

From the Guidelines

The correct answer is C. Increase intra-abdominal pressure is the most likely cause of the hiatal hernia in this obese middle-aged lady with GORD symptoms and gastroesophageal junction above the diaphragm. Obesity is a significant risk factor for hiatal hernias because the excess adipose tissue in the abdomen increases intra-abdominal pressure, which pushes the stomach upward through the diaphragmatic hiatus. This mechanical force gradually weakens the phrenoesophageal membrane and diaphragmatic crura, allowing the gastroesophageal junction to migrate above the diaphragm. The increased pressure also compromises the lower esophageal sphincter function, exacerbating GORD symptoms. While wide crura (option A) can be a contributing anatomical factor in some cases, the primary driving force in obese patients is specifically the increased intra-abdominal pressure, making option C the most appropriate answer for this clinical scenario. Some key points to consider in this scenario include:

• The role of obesity in increasing intra-abdominal pressure and its impact on the development of hiatal hernias 1
• The mechanical forces involved in the migration of the gastroesophageal junction above the diaphragm
• The compromise of lower esophageal sphincter function and its contribution to GORD symptoms
• The importance of considering lifestyle modifications, such as weight loss, in the management of GORD symptoms 1 It is essential to prioritize the management of GORD symptoms and the underlying cause of the hiatal hernia to prevent further complications and improve the patient's quality of life.

From the Research

Causes of Hernia in Obese Middle-Aged Lady with GORD

The lady's symptoms can be attributed to several factors, including:

• Increased intra-abdominal pressure due to obesity, which can cause the gastroesophageal junction to be displaced above the level of the diaphragm 2, 3
• Wide crura, which can contribute to the development of a hiatus hernia, although this is not directly related to the lady's obesity or GORD symptoms 2

Relationship Between Obesity and GORD

Obesity is a significant risk factor for GORD, and increased intra-abdominal pressure is thought to play a key role in the development of reflux symptoms 2, 3

• Abdominal obesity can cause GORD by elevating intra-abdominal pressure, which promotes reflux and the development of hiatus hernia 3
• Weight loss can reduce symptoms and proton pump inhibitor use and dosage in patients with GORD, suggesting that obesity is a modifiable risk factor for the condition 4

Possible Causes of the Lady's Hernia

Based on the evidence, the possible causes of the lady's hernia are:

• Increased intra-abdominal pressure due to obesity, which can cause the gastroesophageal junction to be displaced above the level of the diaphragm 2, 3
• The correct answer is therefore A or C, with increased intra-abdominal pressure being the most likely cause of the lady's hernia 2, 3