From the Guidelines
Hiatal hernias should be managed based on their type and severity, with lifestyle modifications and medications being the first line of treatment, and surgical repair reserved for severe cases or those with significant complications, as recommended by the most recent guidelines 1.
Classification of Hiatal Hernias
Hiatal hernias can be classified into four main types:
- Type I: Sliding hiatal hernia, the most common type (90%), where the esophageal hiatus is widened, allowing herniation of the gastric cardia and migration of the gastroesophageal junction above the diaphragm.
- Type II: Paraesophageal hiatal hernia, accounting for 10% of hiatal hernias, where the defect is in the phrenoesophageal membrane, allowing herniation of the gastric fundus while preserving the gastroesophageal junction in a normal position.
- Type III: A combination of Type I and Type II hiatal hernias, a paraesophageal hiatal hernia with a superiorly displaced gastroesophageal junction.
- Type IV: A significantly large diaphragmatic hernia that can accommodate the herniation of additional viscera, including the stomach, colon, and spleen.
Treatment Options
For mild cases, lifestyle modifications are recommended, including:
- Avoiding large meals
- Not lying down after eating
- Maintaining a healthy weight
- Quitting smoking
- Limiting alcohol consumption Medications that reduce stomach acid can help manage symptoms, including:
- Over-the-counter antacids for occasional discomfort
- H2 blockers like famotidine (20mg twice daily)
- Proton pump inhibitors such as omeprazole (20mg daily before breakfast) for more persistent symptoms For severe cases causing significant reflux, difficulty swallowing, or pain, surgical repair may be necessary, with the most common procedure being Nissen fundoplication, where the stomach is wrapped around the lower esophagus to strengthen the barrier against acid reflux 1.
Management of Complicated Diaphragmatic Hernias
In cases of complicated diaphragmatic hernias, laparoscopic repair seems to be the best treatment option for stable patients, while open repair is considered necessary in the majority of unstable patients, where damage control surgery can be life-saving 1.
Additional Treatment Options
For patients with persistent symptoms, adding sodium alginate to proton pump inhibitors (PPIs) can result in a significantly greater rate of complete resolution of heartburn, and baclofen, a GABA agonist, can be used as an add-on therapy to PPIs, but is limited by side effects 1.
From the Research
Hiatal Hernia Overview
- Hiatal hernia is a condition where part of the stomach pushes up into the chest through an opening in the diaphragm [(2,3,4,5)].
- The presence of hiatal hernia can affect the treatment of gastroesophageal reflux disease (GERD) and the dosage of proton pump inhibitors (PPIs) required for effective intra-oesophageal acid suppression [(2,3)].
Treatment of Hiatal Hernia
- Proton pump inhibitors (PPIs) such as lansoprazole and esomeprazole are commonly used to treat GERD symptoms in patients with hiatal hernia [(2,3,6)].
- The dosage of PPIs required for effective treatment may be higher in patients with hiatal hernia compared to those without [(2,3)].
- A study found that a 30-mg daily dosage of lansoprazole was effective in normalizing oesophageal acid exposure in patients without hiatal hernia, but a 60-mg daily dosage was necessary in patients with hiatal hernia 2.
- Another study found that a standard dose of esomeprazole (40 mg once daily) was effective in normalizing esophageal acid exposure in 84.2% of patients, but a double dose (40 mg twice daily) was required in patients with hiatus hernia 3.
Postoperative Care
- The use of PPIs after hiatal hernia repair may delay proper workup to identify recurrent hiatal hernia and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms 4.
- A study found that early postoperative use of a proton pump inhibitor (sodium rabeprazole) was effective in relieving symptoms of hiatal hernia after open heart surgery 5.
Efficacy of PPIs
- Lansoprazole, a new proton pump inhibitor, was found to be highly effective in healing erosive reflux esophagitis resistant to therapy with histamine H2-receptor antagonists 6.
- The efficacy of PPIs in treating GERD symptoms in patients with hiatal hernia may be influenced by the presence of hiatal hernia, with higher doses required in patients with hiatal hernia [(2,3)].