Makindo Medical Notes

Hiatus hernia occurs when part of the stomach pushes through the diaphragm into the chest cavity. While often asymptomatic, it can lead to gastroesophageal reflux disease (GORD) and other complications if left unmanaged. Early detection and appropriate treatment are essential to prevent severe outcomes.

About Hiatus Hernia

Hiatus Hernia is a condition where a portion of the stomach protrudes through the oesophageal hiatus of the diaphragm into the thoracic cavity. This anatomical displacement can disrupt normal digestive processes and contribute to various gastrointestinal symptoms. Hiatus hernias are classified mainly into two types: sliding and paraesophageal.

• Involves weakened diaphragmatic sphincter.
• The lower esophagus and cardiac portion of the stomach rise into the thorax.
• Common anatomical variation that can affect digestive health.

Aetiology

The development of a hiatus hernia is influenced by several factors that weaken the diaphragmatic sphincter or increase intra-abdominal pressure, facilitating the herniation of the stomach into the thoracic cavity.

• Gastroesophageal Reflux Disease (GORD): Often associated with hiatus hernia, where acid reflux can weaken the diaphragmatic sphincter over time.
• Obesity: Excess body weight increases intra-abdominal pressure, promoting herniation.
• Age-Related Changes: Degeneration of connective tissues and weakening of the diaphragmatic muscles with age.
• Genetic Predisposition: Family history may play a role in susceptibility.
• Trauma or Injury: Physical trauma to the abdomen can disrupt diaphragmatic integrity.
• Pregnancy: Increased intra-abdominal pressure during pregnancy can contribute to the development of hiatus hernia.

Clinical Presentation

Hiatus hernia is often asymptomatic, but when symptoms are present, they are usually related to gastroesophageal reflux and can significantly impact the quality of life.

• Asymptomatic: Many individuals may not experience any noticeable symptoms.
• GORD Symptoms: Heartburn, regurgitation, chest pain, and sour taste in the mouth.
• Dysphagia: Difficulty swallowing can be a red flag for oesophageal cancer, necessitating urgent referral.
• Chest Pain: Can mimic angina, making differential diagnosis important.
• Belching and Bloating: Excessive gas and abdominal discomfort.
• Hoarseness or Sore Throat: Due to acid reflux irritating the vocal cords.

Differential Diagnosis

Several conditions can present with symptoms similar to those of a hiatus hernia. It is crucial to differentiate between these to ensure accurate diagnosis and appropriate management.

• Gastroesophageal Reflux Disease (GORD) without Hernia: Similar reflux symptoms but without anatomical herniation.
• Angina Pectoris: Chest pain related to cardiac ischaemia, requiring differentiation from reflux-induced chest pain.
• Esophageal Cancer: Presents with dysphagia, weight loss, and may mimic severe hiatus hernia symptoms.
• Achalasia: A motility disorder of the esophagus causing difficulty in swallowing and chest pain.
• Peptic Ulcer Disease: Can cause epigastric pain and dyspepsia similar to reflux symptoms.
• Hiatal Abscess: Rare but can present with similar symptoms and requires prompt treatment.

Investigations

Diagnostic investigations aim to confirm the presence of a hiatus hernia, assess the severity of associated symptoms, and rule out other potential conditions.

• Laboratory Tests:
  • Complete Blood Count (CBC): To check for anemia, which may suggest chronic bleeding from erosive esophagitis.
  • Urea & Electrolytes (U&E): To assess overall metabolic status.
  • Liver Function Tests (LFTs): To rule out hepatic causes of symptoms.
  • C-Reactive Protein (CRP): To detect inflammation.
  • Blood Glucose: To screen for diabetes mellitus.
  • Osmolality: Particularly in cases with suspected diabetes insipidus.
• Endocrine Evaluation:
  • Check pituitary function including cortisol, Growth Hormone (GH), Thyroid Function Tests (TFT), Prolactin (PRL), estrogen, and testosterone.
  • Short Synacthen Test: To assess adrenal gland function if indicated.
• Imaging Studies:
  • Barium Swallow: An X-ray imaging technique where the patient swallows barium to visualize the esophagus and stomach, identifying herniation and assessing swallowing function.
  • Oesophagogastroduodenoscopy (OGD): Endoscopic examination to visualize the esophagus, stomach, and duodenum, identifying esophagitis, hiatus hernia, Barrett's esophagus, or malignancies.
  • Chest X-Ray: May incidentally detect a hiatus hernia as a retrocardiac mass.
  • High-Resolution CT Scan or MRI: Provides detailed anatomical visualization if needed.
• Other Tests:
  • Manometry: To assess oesophageal motility in cases with dysphagia.
  • pH Monitoring: To quantify acid reflux severity.

Management

Management of a hiatus hernia depends on the severity of symptoms and the presence of complications. Treatment aims to alleviate symptoms, prevent complications, and address the underlying causes.

• Lifestyle Modifications:
  • Weight Reduction: Achieving and maintaining a healthy weight to decrease intra-abdominal pressure.
  • Smaller, Frequent Meals: Reduces the volume of stomach contents, minimizing reflux.
  • Avoid Trigger Foods: Such as coffee, alcohol, chocolate, spicy foods, and fatty foods that exacerbate reflux symptoms.
  • Elevate the Head of the Bed: Helps prevent nighttime reflux by using pillows or bed wedges.
  • Avoid Lying Down After Meals: Wait at least 2-3 hours before reclining to reduce reflux risk.
• Pharmacological Treatments:
  • Antacids: Provide quick relief by neutralizing stomach acid.
  • Proton Pump Inhibitors (PPIs) and H2 Blockers: Reduce acid production, heal erosive esophagitis, and alleviate GORD symptoms.
  • Prokinetic Agents: Enhance gastric emptying and improve lower oesophageal sphincter function.
• Endoscopic Treatments:
  • Endoscopic Fundoplication: A procedure to reinforce the lower oesophageal sphincter and prevent reflux.
• Surgical Intervention: Indicated in cases with severe symptoms, complications, or failure of medical management.
  • Fundoplication (e.g., Nissen Fundoplication): Surgical procedure where the stomach is wrapped around the lower esophagus to strengthen the sphincter.
  • Hiatoplasty: Repair of the diaphragmatic hiatus to prevent herniation.
  • Robotic or Laparoscopic Surgery: Minimally invasive approaches to reduce recovery time and surgical risks.
• Monitoring and Follow-Up:
  • Regular follow-up appointments to assess treatment efficacy and adjust therapies as needed.
  • Monitoring for complications such as Barrett's esophagus or oesophageal adenocarcinoma in long-standing GORD.

Prognosis

The prognosis for individuals with a hiatus hernia is generally favorable, especially when managed appropriately. Most patients experience significant relief from symptoms with lifestyle modifications and pharmacological treatments. Surgical intervention provides long-term symptom control and prevents complications in severe cases.

• Asymptomatic Cases: Often require no treatment but should be monitored periodically for any changes.
• Symptomatic Cases: Respond well to medical and lifestyle interventions, with most patients achieving symptom resolution.
• Complicated Cases: Require surgical management to prevent serious complications such as strangulation or severe reflux leading to oesophageal damage.
• Long-Term Outlook: With effective management, individuals can maintain a good quality of life. However, adherence to lifestyle changes and medical therapies is crucial to prevent recurrence and complications.

Conclusion

Hiatus hernia is a prevalent condition that can range from being asymptomatic to causing significant gastrointestinal distress. Early detection and appropriate management are essential to alleviate symptoms, prevent complications, and improve the overall quality of life. A combination of lifestyle modifications, pharmacological treatments, and surgical interventions offers effective strategies for managing hiatus hernia. Regular monitoring and follow-up care ensure that any progression or complications are promptly addressed, maintaining optimal digestive health.

References

• Mayo Clinic. Hiatus Hernia. Available at: https://www.mayoclinic.org
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Hiatal Hernia. Available at: https://www.niddk.nih.gov
• American College of Gastroenterology. Hiatal Hernia. Available at: https://gi.org
• Kahrilas, P. J. (2008). Hiatal Hernia and GERD: Role of the Diaphragmatic Hiatus. Current Gastroenterology Reports.
• Fass, R., et al. (2014). Hiatal Hernia: Clinical Presentation and Diagnosis. Clinics in Colon and Rectal Surgery.
• British Society of Gastroenterology. Management of Gastroesophageal Reflux Disease (GORD). Available at: https://www.bsg.org.uk