A hiatus hernia (hiatal hernia) means protrusion of the stomach through the hiatus into the thoracic cavity. The diagnosis can be confirmed by gastroscopy and it is often an incidental finding.
In a sliding hernia, the junction between the oesophagus and the stomach slides up into the thoracic cavity. These are treated like ordinary gastro-oesophageal reflux disease (GORD).
In a para-oesophageal hernia, a significant part of the stomach is situated in the thoracic cavity. This often causes difficulty eating, vomiting, pain or dyspnoea.
No intervention is needed if there is an asymptomatic para-oesophageal hernia. Symptomatic cases should be referred for non-urgent surgical assessment.
General remarks
A couple of centimetres of the oesophagus are normally situated in the abdominal cavity. The junction between the oesophagus and the stomach is clearly on the side of the abdominal cavity.
If the junction between the oesophagus and the stomach protrudes through the hiatus to above the diaphragm, this is known as a hiatus hernia.
A hiatus hernia develops when supporting structures stretch with age and with increased intra-abdominal pressure.
In addition to individual characteristics, factors such as obesity, chronic cough or physical exertion may predispose a person to a hiatus hernia.
Classification
Hiatus hernias can be divided into four types.
Type 1: sliding hernia (axial hernia), where, as the name says, the junction between the oesophagus and the stomach has slid to above the diaphragm.
Type 2: a para-oesophageal hernia, where there is a hiatus hernia by the oesophagus but the junction between the oesophagus and the stomach is still situated below the diaphragm; this is rare.
Type 3: the fundus of the stomach and usually a significant proportion of the stomach have slid into the thoracic cavity; the most common para-oesophageal hernia.
Type 4: a para-oesophageal hernia, where organs other than the stomach slide into the thoracic cavity.
In practice, division into two, i.e. sliding hernia (type 1) and para-oesophageal hernia (types 2-4) is quite sufficient, as the definitions of a large sliding hernia and para-oesophageal hernia actually overlap F1.
Rarer types of diaphragmatic hernia include congenital Morgagni hernia situated anteriorly in the diaphragm, underneath the sternum, and Bochdalek hernia situated posteriorly in the diaphragm.
In the worst case, a para-oesophageal hernia may be incarcerated, causing gastric necrosis.
The risk is relatively low (1-2% per year).
Sliding hernias do not become incarcerated.
Workup
Typical symptoms of GORD responding to treatment in patients under 50-55 years of age without any alarm symptoms do not require further investigations Gastro-Oesophageal Reflux Disease.
If medication with proton pump inhibitors (PPI) proves insufficient, the patient should be referred for gastroscopy Gastroscopy.
Gastroscopy is a basic examination in patients with unclear upper abdominal symptoms Dyspepsia, pain associated with eating, vomiting or anaemia.
If the gastroscopy finding is unclear, CT is excellent for showing hiatus hernias.
A large hiatus hernia may also be visible in plain thoracic x-ray F2F3.
Lifestyle guidance, such as instruction to elevate the head of the bed
Avoiding eating in the evening
PPI medication
Don't be afraid of even long-term use of PPIs in cases with clear indications.
In some cases, PPIs do not provide a sufficient response.
Surgical treatment of GORD can be considered if the symptom is objectively associated with reflux.
Oesophagitis showing severe reflux
pH impedance testing in specialized care
Also very large sliding hernias with a large proportion of the stomach intruding into the thoracic cavity often end up being treated surgically.
Type 2-4, or para-oesophageal, hernias
No intervention is necessary for asymptomatic hernias or ones with minor symptoms.
Patients with clear symptoms despite medication can be referred for surgical assessment.
In surgical treatment, the stomach is lowered to the abdominal cavity, the hiatus is tightened and an antireflux procedure, i.e. fundoplication, is performed.
The surgical procedure is done laparoscopically, and it is very safe.
The quality of life improves in about 90% of patients.
However, surgical treatment involves the problem of quite high recurrence of hernias; about 10% of patients require repeat surgery.
If a patient who has undergone fundoplication or repair of hiatus hernia starts complaining about heartburn, vomiting or upper abdominal pain, this is usually due to either recurrence or a mechanical problem.
Non-urgent referral to a surgery unit is required.
Morgagni and Bochdalek hernias
Particularly hernias producing symptoms are readily treated with surgery. Surgical assessment should be performed in specialized care.
References
Lidor AO, Steele KE, Stem M, et al. Long-term quality of life and risk factors for recurrence after laparoscopic repair of paraesophageal hernia. JAMA Surg 2015;150(5):424-31 [PubMed]