Hiatus Hernia

Gastroenterology (12%) Core Clinical Conditions

1B The Physician Associate is able to identify the condition as a possible diagnosis: may not have the knowledge/resources to confirm the diagnosis or to manage the condition safely, but can take measures to avoid immediate deterioration and refer appropriately.

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Definition Aetiology Pathophysiology Sign and Symptoms Investigations Management

Hiatus hernia is a common medical condition that affects the upper digestive system. It occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity. In this article, we will define hiatus hernia,

Hiatus hernia, also known as hiatal hernia, is a condition characterised by the displacement of part of the stomach into the chest through the hiatus. The hiatus refers to the opening in the diaphragm that allows the oesophagus to pass through and connect to the stomach. Hiatus hernias can be categorised into two types: sliding hiatus hernia and paraesophageal hiatus hernia.

1. Age: Hiatus hernias are more common in individuals over the age of 50.
2. Obesity or excess weight: An increased body mass index (BMI) can put additional pressure on the muscles around the hiatus.
3. Pregnancy: The growing uterus can place pressure on the stomach, leading to hiatus hernia in some pregnant women.
4. Smoking: Chronic coughing associated with smoking can weaken the muscles involved.
5. Genetics: There may be a genetic predisposition to developing hiatus hernia.

There are two main types of hiatus hernia:
1. Sliding Hiatus Hernia: This is the most common type, accounting for approximately 95% of cases. In a sliding hiatus hernia, the gastroesophageal junction and a part of the stomach slide up into the chest through the hiatus. This type of hernia is usually associated with Gastro-oesophageal reflux disease (GORD).
2. Paraesophageal Hernia: In this less common type of hiatus hernia, a part of the stomach squeezes through the hiatus and settles alongside the oesophagus. Unlike a sliding hiatus hernia, the gastroesophageal junction remains in place. Paraesophageal hernias carry a greater risk of complications, such as incarceration or strangulation.

Underlying Mechanisms

The pathophysiology of hiatus hernia is multifactorial and involves a combination of anatomical, mechanical, and physiological factors. Several mechanisms contribute to the development of this condition:
1. Hiatal Weakness: A weakening of the diaphragm's muscles and surrounding tissues can create a larger than normal hiatus. This can be congenital (present at birth) or acquired over time due to factors such as ageing, obesity, pregnancy, or increased intra-abdominal pressure.
2. Intra-abdominal Pressure: Any condition or activity that increases intra-abdominal pressure can contribute to the development of a hiatus hernia. Chronic coughing, constipation, heavy lifting, vomiting, or straining during bowel movements may all exert pressure that pushes a portion of the stomach upward into the chest cavity.
3. Connective Tissue Disorders: Some connective tissue disorders, such as Marfan syndrome or Ehlers-Danlos syndrome, can affect the strength and integrity of the diaphragm and surrounding tissues, making them more susceptible to hiatal herniation.
4. Age and Degeneration: Hiatus hernias tend to be more common in older individuals as the tissues weaken and natural degenerative changes occur. With advancing age, the risk of developing this condition increases.

1. Heartburn: A burning sensation or discomfort behind the breastbone, often worsened by lying down or bending over.

2. Regurgitation: Sour or acidic taste in the mouth due to the backflow of stomach acid into the oesophagus.

3. Difficulty swallowing: Feeling like food is stuck in the throat or chest.

4. Chest pain: Sometimes confused with a heart attack, chest pain related to hiatus hernia is typically worsened by lying down or consuming large meals.

5. Belching or hiccups: Frequent burping or hiccups, often unrelated to meals, may occur.

1. Patient history: The PA will ask about the patient's symptoms, such as heartburn, regurgitation, chest pain, and difficulty swallowing. Additionally, they will inquire about any risk factors or predisposing conditions that might contribute to the development of a hiatus hernia, such as obesity, smoking, or pregnancy.

2. Physical examination: A physical examination is performed to assess the patient's symptoms and identify any potential signs of a hiatus hernia. The PA will examine the patient's abdomen for any palpable abnormalities or tenderness. They may also conduct a chest examination to listen for abnormal sounds or evaluate for associated respiratory issues.

3. Upper gastrointestinal (GI) endoscopy: Upper GI endoscopy is considered the gold standard for diagnosing a hiatus hernia. During this procedure, a flexible tube with a light and camera (endoscope) is inserted through the mouth and oesophagus into the stomach. It allows the healthcare provider to visualise the oesophagus and stomach, assess the size and location of the hernia, and identify any associated complications such as inflammation (esophagitis), ulcers, or Barrett's oesophagus.

4. Barium swallow X-ray: Another commonly used diagnostic tool for hiatus hernia is a barium swallow X-ray. In this procedure, the patient drinks a contrast solution containing barium, which coats the oesophagus and stomach. X-ray images are then taken as the patient swallows the solution. This helps to identify the presence of a hernia, its size, and any abnormalities that may be associated with it.

5. CT (computed tomography) scan: In certain cases, a CT scan may be used to obtain a cross-sectional image of the chest and abdomen. This can help assess the size and location of the hiatus hernia, as well as identify any complications or associated abnormalities.

1. Lifestyle changes: Adopting healthier habits, such as maintaining a healthy weight, avoiding large meals, elevating the head of the bed, quitting smoking, and avoiding triggering foods or beverages that worsen symptoms.
2. Medications: Over-the-counter or prescription medications, such as antacids, proton pump inhibitors such as Lansoprazole, or H2 blockers such as Ranitidine , can help relieve acid reflux and manage symptoms.
3. Surgery: In severe cases when lifestyle modifications and medications are ineffective, surgical intervention may be necessary. Minimally invasive procedures, such as laparoscopic repair, can restore normal anatomy and improve symptoms.

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