Hiatus Hernia
Summary
Hiatus Hernia (HH) is the protrusion of abdominal viscera (usually the stomach) through the oesophageal hiatus of the diaphragm into the mediastinum. It is extremely common (>50% of over 50s). The clinical significance depends entirely on the type:
- Type I (Sliding): The commonest (95%). Associated with GORD.
- Type II-IV (Rolling/Para-oesophageal): Rare but dangerous. Associated with volvulus and strangulation. [1,2]
Classification (The 4 Types)
- Type I (Sliding): The Gastro-Oesophageal Junction (GOJ) migrates superiorly into the chest. Axial herniation.
- Type II (Rolling): The GOJ remains in the abdomen. The gastric fundus herniates alongside the oesophagus.
- Type III (Mixed): Both the GOJ and fundus herniate. Commonest form of "Para-oesophageal" hernia.
- Type IV: Other organs (Spleen, Colon, Omentum) enter the hernia sac.
Clinical Pearls
Cameron's Lesions: A subtly important cause of Iron Deficiency Anaemia. These are linear erosions/ulcers on the crest of the gastric folds where the stomach is pinched by the diaphragm. Always consider HH in "IDA of unknown origin".
The Borchardt Triad: Signs of Acute Gastric Volvulus (Emergency!). > 1. Severe epigastric pain. > 2. Retching without vomiting. > 3. Inability to pass an NG tube.
Retrocardiac Mass: On a CXR, a fluid-filled level behind the heart is a hiatus hernia until proven otherwise.
Demographics
- Prevalence: Increases with age and BMI. 10% in unders 40s; 70% in over 70s.
- Gender: F > M.
Risk Factors
- Intra-abdominal Pressure: Obesity, Pregnancy, Chronic cough, Constipation.
- Muscle Weakness: Ageing (phreno-oesophageal ligament laxity).
- Previous Surgery: Oesophagectomy / Anti-reflux surgery.
Mechanisms
- Type I: The Lower Oesophageal Sphincter (LOS) moves into the negative-pressure thorax. The "Angle of His" is flattened. Both factors promote Acid Reflux.
- Type II: The stomach rotates around its axis (organo-axial volvulus). This obstructs the blood supply (ischaemia) and the outlet (obstruction).
Type I (Sliding)
Type II-IV (Para-oesophageal)
- Usually unremarkable.
- Bowel sounds in chest: Only in massive ruptures/hernias.
First Line
- OGD (Gastroscopy):
- Diagnoses hernia (judged by distance between Z-line and diaphragmatic pinch).
- Assesses mucosal damage (Oesophagitis, Barrett's).
- CXR: Retrocardiac air-fluid level.
Pre-Operative Workup
- Barium Swallow: Essential for surgical planning. Defines the anatomy and size of the defect much better than OGD.
- High Resolution Manometry: To assess oesophageal motility (don't perform a 360 wrap if motility is poor!).
- 24hr pH Studies: Confirms reflux burden.
Management Algorithm
HIATUS HERNIA DIAGNOSED
↓
DEFINE TYPE
┌─────────┴─────────┐
TYPE I TYPE II-IV
(Sliding) (Para-oesophageal)
↓ ↓
SYMPTOMATIC? FIT FOR SURGERY?
(Reflux) │
│ ┌────┴────┐
│ YES NO
│ ↓ ↓
MEDICAL Rx ELECTIVE WATCH &
(PPI + REPAIR WAIT
Lifestyle) (Reduce (Risky)
│ Volvulus
│ Risk)
│
REFRACTORY?
↓
ANTI-REFLUX
SURGERY
Refractory = Failed max dose PPI
or severe Volume Reflux
Surgical Techniques
- Cruroplasty: Reducing the hernia and suturing the diaphragmatic crura (hole) closed. Often reinforced with mesh.
- Fundoplication: Wrapping the stomach around the oesophagus to prevent reflux/recurrence.
- Nissen: 360° total wrap. Most effective for reflux, highest dysphagia risk.
- Toupet: 270° posterior wrap. Better for poor motility.
Hernia Related
- GORD Sequelae: Stricture, Barrett's Oesophagus, Adenocarcinoma.
- Volvulus: Strangulation -> Perforation -> Mediastinitis -> Death.
- Bleeding: Cameron's ulcers.
Surgery Related
- Gas Bloat Syndrome: Inability to belch/vomit due to tight wrap. Abdominal distension.
- Dysphagia: Too tight. May need dilation.
- Medical: PPIs control symptoms in 80% of Type I.
- Surgical: >90% satisfaction rate for para-oesophageal repair. Recurrence of hernia (anatomical) is common (20-30%) but recurrence of symptoms is lower.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Hiatal Hernia | SAGES (2013) | Repair all symptomatic para-oesophageal hernias. Asymptomatic Type II usually watched now (shift from prophylactic repair). |
| GORD | NICE (NG184) | PPI titration. |
Landmark Evidence
1. The "Watchful Waiting" Debate
- Old dogma: Repair all Type IIs to prevent death.
- New data: Risk of emergency volvulus is actually low (less than 2% per year). Risk of elective surgery in elderly is high. Now we tend to watch asymptomatic Type IIs in frail patients.
What is a Hiatus Hernia?
Usually, the stomach sits in the tummy, below the breathing muscle (diaphragm). A hiatus hernia is when the stomach squeezes up through the small gap meant for the food pipe, entering the chest.
Why does it cause heartburn?
The diaphragm normally helps pinch the top of the stomach closed to keep acid in. When the stomach slides up, this pinch is lost, and acid splashes up into the gullet.
Is it dangerous?
The "Sliding" type is annoying (heartburn) but rarely dangerous. The "Rolling" type (where the stomach twists up next to the gullet) can get stuck and strangle itself. This is a medical emergency.
What is the operation?
Keyhole surgery to pull the stomach back down, stitch the hole smaller, and wrap the top of the stomach around the food pipe to make a new valve.
Primary Sources
- Kohn GP, et al. Guidelines for the management of hiatal hernia. SAGES. Surg Endosc. 2013.
- NICE Guideline [NG184]. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. 2014.
Common Exam Questions
- Radiology: "Fluid level behind heart?"
- Answer: Hiatus Hernia.
- Emergency: "Borchardt's Triad?"
- Answer: Gastric Volvulus signs (Pain, Retching, No NG pass).
- Treatment: "Investigation determining wrap type?"
- Answer: Manometry (exclude dysmotility).
- Pathology: "Ulcer in hernia sac?"
- Answer: Cameron's lesion.
Viva Points
- Mesh or No Mesh: Use of mesh at the hiatus reduces recurrence rate but carries risk of mesh erosion into the oesophagus (disastrous). Currently controversial.
- Short Oesophagus: Chronic reflux causes the oesophagus to scar and shorten. You can't just pull the stomach down; you might need an oesophageal lengthening procedure (Collis gastroplasty).
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.