Hiatus Hernia

Definition

Types

Bailey & Love's Short Practice of Surgery — Types of hiatal hernia

Causes and Predisposing Factors

Pathophysiology

• Weakening of the phrenoesophageal ligament/membrane — the key structural defect in sliding hernias; allows cephalad displacement of the GOJ
• Dilatation of the diaphragmatic hiatus — normally a slit-like muscular opening in the right crus; becomes more circular with atrophy of surrounding fibres in established hernias
• Increased intraabdominal pressure — chronically disrupts the hiatal apparatus
• Focal defect in the phrenoesophageal membrane — mechanism for rolling/paraesophageal hernias

Risk Factors

• Obesity (abdominal pressure)
• Pregnancy
• Chronic cough / straining (e.g., constipation, heavy lifting)
• Advancing age — incidence increases with age; a "wear and tear" phenomenon
• Hereditary/connective tissue factors — predispose to ligamentous laxity
• Congenitally enlarged oesophageal hiatus — may underlie some cases

Symptoms

Type I (Sliding) Hernia

• Often asymptomatic — many patients have no significant symptoms
• Heartburn (pyrosis) — most common complaint; due to GERD resulting from impairment of the anti-reflux barrier
• Acid regurgitation
• Dysphagia — particularly with associated stricture or Schatzki ring
• Chest pain — can mimic cardiac pain

Type II, III, IV (Paraesophageal) Hernias

• Postprandial epigastric or chest pain
• Substernal fullness / bloating
• Shortness of breath (large hernias compress lungs)
• Nausea and vomiting
• Iron deficiency anaemia — from chronic blood loss via Cameron ulcers (linear gastric erosions at the diaphragmatic level)
• Gastric volvulus — in large hernias, can cause acute severe pain, inability to vomit, and inability to pass nasogastric tube (Borchardt's triad)
• Strangulation / obstruction — uncommon but life-threatening emergency

Although most patients with GERD have a hiatus hernia, most patients with a hiatus hernia do not have significant reflux. — Miller's Anesthesia 10e

Investigations

1. Endoscopy (OGD — Oesophagogastroduodenoscopy)

• Most accurate for identifying mucosal complications: reflux oesophagitis, Barrett's oesophagus, Cameron ulcers, strictures
• Diagnostic finding: gastric rugae seen passing through the diaphragmatic hiatus; or oesophageal B ring (squamocolumnar junction) visualised above the diaphragm

Endoscopic image showing gastric folds passing through the extrinsic narrowing of the diaphragmatic hiatus — Grainger & Allison's Diagnostic Radiology

2. Barium Swallow (Fluoroscopy)

• Useful for identifying anatomy and type of hernia
• Sliding hernia confirmed when gastric rugae traverse the diaphragm or the B ring is above the diaphragm
• Less accurate for small (<2 cm) sliding hernias
• Best modality for rolling and mixed-type hernias alongside CT
• Assessment of gastric volvulus possible

3. CT Scan of the Chest/Abdomen

• Excellent for large hernias, paraesophageal hernias, and complex anatomy
• Identifies herniated contents, hernia size, and complications
• Gold standard for Type III and IV hernias

Multimodal imaging: (a) barium esophagogram Type I sliding hernia; (b) barium Type III mixed hernia; (c) CT Type IV hernia with colon and multiple viscera in chest

4. High-Resolution Manometry (HRM)

• Current gold standard for diagnosing small sliding hiatal hernias
• Measures lower oesophageal sphincter (LES) pressure, length, and position
• Separates LES pressure from crural diaphragm contribution
• Identifies deficient anti-reflux barrier components

5. 24-Hour Ambulatory pH Monitoring

• Gold standard for establishing the presence and degree of gastro-oesophageal reflux
• Confirms pathological acid exposure time
• Used in surgical planning

6. Chest X-Ray

• May show retrocardiac air-fluid level or air-filled viscus behind the heart in large hernias
• Incidental finding of dilated intrathoracic stomach

Treatment

Conservative / Medical Management (Type I — Sliding)

• Weight loss (reduce abdominal pressure)
• Elevate head of bed
• Small, frequent meals; avoid meals 2–3 hours before lying down
• Avoid precipitants: alcohol, smoking, fatty foods, caffeine, chocolate, NSAIDs

• Proton pump inhibitors (PPIs) — first-line; e.g., omeprazole, lansoprazole; suppress acid secretion
• H₂-receptor antagonists — alternative or adjunct
• Antacids / alginates — for symptomatic relief of breakthrough symptoms
• Prokinetics — may help with delayed gastric emptying

Surgical Management

• Failed or intolerable medical therapy
• Symptomatic paraesophageal hernias (Types II, III, IV)
• Complications: strangulation, obstruction, volvulus, bleeding, perforation
• Large hernias with iron deficiency anaemia
• Patient preference to stop lifelong medication

1. Reduction of the hernia back into the abdomen
2. Crural repair — closure of the diaphragmatic hiatus with permanent sutures ± mesh reinforcement
3. Fundoplication — wrapping of the gastric fundus around the lower oesophagus to restore the anti-reflux barrier

• Nissen fundoplication (360° wrap) — most common; best for normal or near-normal oesophageal motility
• Partial fundoplication (Toupet 270° posterior; Dor 180° anterior) — preferred when oesophageal dysmotility is present

• Laparoscopic — now the standard approach; lower morbidity, shorter hospital stay, faster recovery
• Open laparotomy or thoracotomy — reserved for re-operative cases, failed laparoscopy, or complex anatomy

• Recurrence rates with primary suture closure alone: 10–40%
• Biologic or synthetic mesh reduces recurrence; biologic mesh widely used due to lower erosion risk

• Dysphagia is a potential complication of overly tight fundoplication
• Recurrence can occur (intrathoracic wrap migration)

Key Summary Table