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 and gastroesophageal junction above the diaphragm. Obesity significantly increases intra-abdominal pressure, which pushes the stomach upward through the diaphragmatic hiatus, as described in the context of diaphragmatic injuries and hernias 1. This mechanical force gradually weakens the phrenoesophageal ligament and enlarges the hiatal opening, allowing the gastroesophageal junction to migrate above the diaphragm, creating a sliding hiatal hernia. The increased pressure also compromises the lower esophageal sphincter function, exacerbating GORD symptoms. Some key points to consider in this scenario include:

• The natural history of traumatic diaphragmatic injury with hernia formation, which has been described to have three phases: the acute phase, the latent phase, and the obstructive phase 1.
• The effects of the diaphragmatic rupture are primarily on the circulation and respiration, resulting in a 25–50% decrease in the pulmonary function, with the most common symptoms being dyspnea and abdominal pain 1.
• While wide crura (option A) can be a contributing anatomical factor in some cases, the primary mechanical force in obese patients is the increased intra-abdominal pressure, which directly correlates with body mass index and waist circumference, as implied by the discussion on the management of complicated diaphragmatic hernia in the acute setting 1. Weight loss is often recommended as part of treatment to reduce this pressure and potentially improve both the hernia and GORD symptoms.

From the Research

Hiatal Hernia Cause

The cause of the hernia in an obese middle-aged lady with symptoms of GORD and the gastroesophageal junction above the level of the diaphragm can be attributed to several factors.

• Increase in intra-abdominal pressure is a significant factor, as stated in the study 2, which promotes reflux and the development of hiatus hernia.
• Abdominal obesity is a key contributor to GORD by elevating intra-abdominal pressure, as mentioned in the study 2.
• The relationship between central adiposity and GORD complications, including oesophageal adenocarcinoma, is also a concern, as discussed in the study 3.
• Other factors such as age, genetics, pregnancy, and trauma may also contribute to mechanical impairment of the oesophagogastric junction, resulting in pathological reflux and accompanying syndromes, as mentioned in the study 3.

Relevant Factors

The following factors are relevant to the cause of the hernia:

• Increase in intra-abdominal pressure due to abdominal obesity, as stated in the study 2.
• Mechanical impairment of the oesophagogastric junction due to various factors, as discussed in the study 3.
• The presence of hiatal hernias in morbidly obese patients, as reported in the study 4, with a prevalence of 37.0% based on preoperative upper GI contrast study.

Answer Choice

Based on the information provided, the correct answer choice is: A or C, as increase in intra-abdominal pressure is a significant factor in the development of hiatus hernia, as stated in the study 2.