Hiatus Hernia

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Referral

Definition

Hiatus hernia is the protrusion of part of the stomach through the diaphragmatic hiatus into the thoracic cavity. It is commonly associated with gastro-oesophageal reflux disease (GORD).

Aetiology

There are two main types:

  • Sliding hiatus hernia (90% of cases): the gastro-oesophageal junction (GOJ) and stomach move upwards through the hiatus.
  • Para-oesophageal (rolling) hiatus hernia: the stomach herniates alongside the oesophagus, while the GOJ remains in place. This type has a higher risk of complications.

Pathophysiology

  • The diaphragm normally acts as a barrier to prevent gastric reflux.
  • In a hiatus hernia, loss of this barrier function leads to increased acid reflux into the oesophagus.
  • Chronic acid exposure can cause oesophagitis, Barrett’s oesophagus, or oesophageal ulceration.

Risk factors

  • Older age (due to weakening of diaphragmatic support structures).
  • Obesity (increased intra-abdominal pressure).
  • Chronic cough or straining (e.g., chronic obstructive pulmonary disease, constipation).
  • Pregnancy.
  • Previous gastric surgery.
  • Congenital factors (e.g., connective tissue disorders like Marfan syndrome).

Signs and symptoms

Symptoms:

  • Heartburn (worsened by lying flat or bending forward).
  • Regurgitation of food or acid.
  • Epigastric discomfort or chest pain.
  • Dysphagia (difficulty swallowing).
  • Chronic cough, hoarseness, or sore throat (due to reflux-induced irritation).

Signs:

  • Generally, no specific findings on examination.
  • May have epigastric tenderness or signs of anaemia if chronic bleeding occurs.

Investigations

  • Upper GI endoscopy: firs step to assess for oesophagitis, Barrett’s oesophagus, or ulceration.
  • Barium swallow: for detecting hernia type and size.
  • Oesophageal manometry and pH monitoring: performed if reflux symptoms persist despite treatment.

Management

1. Lifestyle and Medical Management:

  • Weight loss: to reduce intra-abdominal pressure.
  • Dietary changes: avoid large meals, caffeine, alcohol, and spicy foods.
  • Head elevation: sleeping with the head raised reduces nocturnal reflux.
  • Proton pump inhibitors (PPIs): e.g., omeprazole/lanzoprazole for symptom control and healing oesophagitis.
  • H2 receptor antagonists: e.g., ranitidine/famotidine (if PPIs are not tolerated).

2. Surgical Management (if severe or refractory) the following types are:

  • Laparoscopic fundoplication: to reinforce the lower oesophageal sphincter (Nissen or Toupet fundoplication).
  • Hernia repair: performed for large para-oesophageal hernias at risk of volvulus.

Referral

  • Gastroenterology referral: if symptoms persist despite PPI therapy.
  • Surgical referral: as above for large, symptomatic para-oesophageal hernias.
  • Urgent referral: 2ww if alarm symptoms (dysphagia, weight loss, persistent vomiting) suggest malignancy.
GastroenterologymypanotesHiatus Hernia