Hiatal hernia Synonyms Hiatus hernia Hiatalhernia.gif A drawing of a hiatal hernia Specialty Gastroenterology, general surgery Symptoms Taste of acid in the back of the mouth, heartburn, trouble swallowing[1] Complications Iron deficiency anemia, volvulus, bowel obstruction[1] Types Sliding, paraesophageal[1] Risk factors Obesity, older age, major trauma[1] Diagnostic method Endoscopy, medical imaging, manometry[1] Treatment Raising the head of the bed, weight loss, medications, surgery[1] Medication H2 blockers, proton pump inhibitors[1] Frequency 10–80% (US)[1] [edit on Wikidata] A hiatal hernia is a type of hernia in which abdominal organs (typically the stomach) slip through the diaphragm into the middle compartment of the chest.

1. Hiatal Hernia
Hiatal hernia is the protrusion of the stomach upward into the
mediastinal cavity through the esophageal hiatus of the
diaphragm.

2. Types of Hiatal Hernia
• 1. Sliding hiatal hernia:
• Herniation of both the stomach and the
• gastroesophageal(GE) junction into the thorax.
• 90% of esophageal hernias
• 2. Paraesophageal hiatal hernia:
• Herniation of all or part of the stomach through the
• esophageal hiatus into the thorax with an undisplaced GE
• junction
• Least common esophageal hernia (<10%)

3. • Type III: Type III hernias have elements of both types I and II hernias.
With progressive enlargement of the hernia through the hiatus, the
phrenoesophageal membrane stretches, displacing the gastroesophageal
junction above the diaphragm, thereby adding a sliding element to the
type II hernia.
• Type IV: Type IV hiatus hernia is associated with a large defect in the
phrenoesophageal membrane, allowing other organs, such as colon,
spleen, pancreas and small intestine to enter the hernia sac.
• The end stage of type I and type II hernias occurs when the whole
stomach migrates up into the chest by rotating 180° around its
longitudinal axis, with the cardia and pylorus as fixed points. In this
situation the abnormality is usually referred to as an intrathoracic
stomach.

4. PATHOPHYSIOLOGY
• Size of hiatus not fixed, narrows with increase in intraabdominal
• pressure
• Tear of Phrenoesophageal ligament :
• is a fibrous layer of connective tissue and maintains the LES
• within the abdominal cavity
• A hiatal hernia compromises reflux barrier
• Reduced LES pressure
• Reduced esophageal acid clearance
• Transient LES relaxation episodes particularly at night time

5. Sliding Hiatal Hernia
• Age
• Increased intra-abdominal pressure (e.g. Obesity, pregnancy,
• coughing, heavy lifting).
• Smoking
Risk factors for Sliding Hiatal Hernia

6. Clinical features
• Majority are asymptomatic
• Heart burn
Larger hernias frequently associated with Gastroesophageal
• reflux disease(GERD) due to decreased competence of theLower
esophageal sphincter (LES) .

7. Complications
• Most common complication is GERD.
• Other complications are rare and are related to reflux
• Esophagitis (dysphagia, heartburn)
• Consequences of esophagitis ( peptic stricture, Barrett’s
• esophagus, esophageal carcinoma)
• Extra-esophageal complications ( pneumonitis/
• pneumonia, asthma, cough, laryngitis)

8. Investigations
• Chest X-ray
• Barium swallow
• Endoscopy
• Esophageal manometry (to measure the pressure of LES)
• 24-48h esophageal pH monitoring to quantify reflux
• Gastroscopy with biopsy to rule out cancer and esophagitis

9. Chest X-ray

10. Barium swallow

11. Endoscopic view:

12. Treatment
• LIFESTYLE MODIFICATION
• Stop smoking,
• weight loss,
• elevate head of bed,
• no meals <3h prior to sleeping,
• smaller and more frequent meals,
• avoid too much alcohol, coffee, mint and fat.

13. • MEDICAL THERAPY
• Antacids
• H2 receptor antagonists e.g. Cimetidine
• Proton pump inhibitors e.g. Omeprazole
• Prokinetic agents e.g. Metoclopramide
SURGICAL THERAPY
Indications:
 Failure of medical therapy
 Esophageal stricture
 Severe nocturnal aspiration
 Barrett’s esophagus

14. • Anti-reflux procedure e.g Fundoplication
• A laparoscopic procedure in which the fundus of the stomach is
• wrapped around lower end of esophagus. The types of fundoplication
• include:
• i. The Nissen fundoplication is total (360°),
• ii. Partial fundoplication known as Thal (270° anterior),
• iii. Belsey (270° anterior transthoracic)
• iv. Dor (anterior 180-200°)
• v. Lind (300° posterior)
• vi. Toupet fundoplication (posterior 270°) are alternative procedures
• with somewhat different indications and outcomes.