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HIATAL HERNIA

Hiatal Hernia : A hiatal hernia is present when a lax or defective phrenoesophageal membrane allows protrusion of the stomach up through the esophageal hiatus of the diaphragm.

The type of hiatal hernia is defined by the location of the GE junction and the relationship of the stomach to the distal esophagus.

1. In type I or sliding hiatal hernia, the phrenoesophageal membrane is intact but lax, thereby allowing the distal esophagus and gastric cardia to herniated through the esophageal hiatus. The GE junction is therefore located above the diaphragm. This is the most common type and is usually asymptomatic.

2. A type II or paraesophageal hiatal hernia occurs when a focal defect is present in the phrenoesophageal membrane, usually anterior and lateral to the esophagus, which allows a protrusion of peritoneum to herniated upward alongside the esophagus through the esophageal hiatus. The GE junction remains anchored within the abdomen, whereas the greater curvature of the stomach rolls up into the chest alongside the distal esophagus. Eventually, most of the stomach can herniate. Because the stomach is anchored at the pylorus and cardia, however, the body of the stomach undergoes a 180-degree organoaxial rotation and ends up as an upside-down, intrathoracic stomach when it is herniated.

3. Type III represents a combination of types I and II. This type is more common than is a pure type II and is characterized by herniation of the greater curvature of the stomach and the GE junction into the chest.

4. A type IV hiatal hernia in which abdominal organs other than or in addition to the stomach herniate through the hiatus. Typically, these hernias are large and contain colon or spleen in addition to the stomach within the chest.

Symptoms and complications in patients with sliding (type I) hiatal hernias are related to associated GE reflux. Paraesophageal and combined (types II, III and IV) hernias frequently produce postprandial pain or bloating, early, satiety, breathlessness with meals and mild dysphagia related to compression of the distal esophagus by the adjacent herniated stomach. The herniated gastric pouch is susceptible to volvulus, obstruction and infarction and can develop ischemic ulcers with frank or occult bleeding.

Daignosis and Evaluation

1. Chest X-ray: The finding of an air-fluid level in the posterior mediastinum on the lateral X-ray suggests the presence of a hiatal hernia. Differential diagnosis includes mediastinal cyst, abscess, or a dilatated obstructed esophagus.

2. A barium swallow confirms the diagnosis and defines any coexisting esophageal abnormalities, including strictures or ulcers, and is the diagnostic study of choice. The positions of the GE junction and proximal stomach define the type of hiatal hernia.

3. Esophagogastroduodenoscopy (EGD) is indicated in patients with symptoms of reflux or dysphagia to determine the degree of esophagitis, presence of a stricture, Barrett’s esophagus or a coexisting abnormality. EGD also establishes the location of the GE junction in relation to the hiatus. A sliding hiatal hernia is present when 2 cm or more of gastric mucosa is present between the diaphragmatic hiatus and the mucosal squamocolumnar junction.

4. Esophageal manometry to evaluate esophageal motility is warranted in patients who are being considered for operative repair.

Management

1. Asymptomatic sliding hernias require no treatment.

2. Patients with sliding hernias and GER with mild esophagitis should undergo an initial trial of medical management.

3. Patients who fail to obtain symptomatic relief with medical therapy or who have severe esophagitis should undergo esophageal testing to determine their suitability for an antireflux procedure and hiatal hernia repair.

4. Patients who do not experience reflux but have symptoms related to their hernia (chest pain, intermittent dysphagia, or esophageal obstruction) should undergo hiatal hernia repair.

5. All patients who are found to have a type II, III or IV hiatal hernia and who are operative candidates should be considered for repair. Medically treated patients with a paraesophageal hernia, even when asymptomatic have nearly a 30% incidence of death from the development of a catastrophic complication. Operative repair can be performed through either an abdominal or thoracic approach and consists of reduction of the hernia, resection of the sac, and closure of the hiatal defect. In combined (type III) hernias, the esophagus frequently is shortened, and therefore a thoracic approach is preferred.

6. Paraesophageal hiatal hernias are associated with a 60% incidence of GER. Furthermore, the operative dissection may lead to postoperative GER in previously asymptomatic patients. Therefore, an antireflux procedure should be performed at the time of hiatal hernia repair.