From the Guidelines
Hiatal hernias should be classified into four main types, including Type I, II, III, and IV, to guide appropriate management and treatment. According to the World Journal of Emergency Surgery 1, hiatal hernias are included in the classification of acquired diaphragmatic hernias, but they are not real diaphragmatic hernias. The most common type is Type I, a sliding hiatal hernia, which accounts for 90% of cases and occurs when the esophageal hiatus is widened enough to allow herniation of the gastric cardia.
Key Characteristics of Hiatal Hernia Types
- Type I: sliding hiatal hernia, most common type (90%)
- Type II: paraesophageal hiatal hernia, accounts for 10% of hiatal hernias
- Type III: combination of Type I and Type II hiatal hernias
- Type IV: significantly large diaphragmatic hernia that can accommodate additional viscera
Management and Treatment
Treatment options for hiatal hernias depend on the severity of symptoms and the size of the hernia. For mild symptoms, lifestyle modifications are recommended, such as avoiding large meals, not lying down after eating, and elevating the head of the bed. Medication options, including antacids, H2 blockers, and proton pump inhibitors, can help reduce stomach acid production and alleviate discomfort. If conservative measures fail, surgical options, such as Nissen fundoplication, may be necessary to strengthen the barrier against acid reflux. As noted in the study 1, hiatal hernias can be managed effectively with a combination of lifestyle modifications, medication, and surgery, depending on the individual case.
From the Research
Hiatal Hernias and Treatment
- Hiatal hernias can affect the dosage of medication required for effective treatment of gastroesophageal reflux disease (GERD) symptoms, with studies suggesting that patients with hiatal hernias may require higher doses of proton pump inhibitors (PPIs) such as lansoprazole 2 and esomeprazole 3.
- The presence of a hiatal hernia can influence the efficacy of PPI therapy, with one study finding that 70% of patients without a hiatal hernia achieved normalized oesophageal acid exposure with a 30-mg daily dosage of lansoprazole, compared to only 28% of patients with a hiatal hernia 2.
- Another study found that a standard dose of esomeprazole (40 mg once daily) was effective in normalizing esophageal acid exposure in 90.5% of patients without a hiatus hernia, but only 53.2% of patients with a hiatus hernia 3.
Proton Pump Inhibitor Use After Hiatal Hernia Repair
- The use of PPIs after hiatal hernia repair may delay proper workup to identify recurrent hiatal hernia, with one study finding that 70% of patients remained or were restarted on PPIs after their initial surgery, and that the time of initiation of PPI was much earlier than the time of identification of a recurrent hiatal hernia 4.
- The study suggests that PPI use 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.
Efficacy of Proton Pump Inhibitors in Relieving Symptoms
- Proton pump inhibitors have been shown to be effective in relieving symptoms of hiatal hernia, with one study finding that a PPI (sodium rabeprazole) was more effective than an H2-receptor antagonist (ranitidine hydrochloride) in relieving GI symptoms and preventing upper GI disorders after cardiac surgery 5.
- The study found that the incidence of gastric pain and heartburn was significantly higher in patients who received the H2-receptor antagonist compared to those who received the PPI 5.