Hiatal hernia may be asymptomatic or may present with heartburn, dysphagia, odynophagia, hoarseness, asthma, shortness of breath, chest pain, anemia or hematemesis, or a combination of these.
Common risk factors are obesity and increased age. Other known risk factors include intra-abdominal pressure from various conditions, and a previous hiatal operation.
Contrasted upper gastrointestinal (GI) series (also known as an upper GI or as a barium esophagram) is the key investigation technique and aids the surgeon in characterizing any anatomic variation necessary for preoperative evaluation. Computed tomography scanning with 3-dimensional reconstruction can be helpful if the diagnosis is unclear, or when planning surgery.
The necessity for, and type of treatment, depends on the patient's symptoms and the anatomic configuration of the hernia.
Uncomplicated sliding hiatal hernias are treated symptomatically with medical therapy, although some patients may select surgical therapy. Complicated hiatal hernias (those with bleeding, volvulus, or obstruction) have a stronger indication for surgical repair.
Hiatal hernia is the protrusion of intra-abdominal contents into the thoracic cavity through an enlarged esophageal hiatus of the diaphragm. Various subtypes exist which are classified anatomically. A hiatal hernia most commonly contains a variable portion of the stomach (type I, II, or III); less commonly, it may contain the transverse colon, omentum, small bowel, or spleen, or some combination of these organs (type IV). Sliding type I hiatal hernias are generally differentiated from the remaining three types, which are collectively referred to as paraesophageal hernias, and the herniated contents are usually contained within a sac of peritoneum.
History and exam
Key diagnostic factors
- bowel sounds in chest
Other diagnostic factors
- chest pain
- shortness of breath
- nonbilious vomiting
- fever and chills
- increased age
- previous gastroesophageal procedure
- elevated intra-abdominal pressure
- male sex
- structural abnormalities of the esophageal hiatus or the phrenoesophageal ligaments
- incisional, umbilical, or inguinal hernia
- disorder of collagen metabolism
1st investigations to order
- chest x-ray
- contrast upper gastrointestinal series (barium esophagram)
Investigations to consider
- CT scan or MRI scan
- high-resolution esophageal manometry and pH monitoring
upper gastrointestinal hemorrhage and/or obstruction and/or volvulus
irreversible organ ischemia and/or necrosis
symptomatic gastroesophageal reflux disease (GERD)
type I refractory to medical therapy or patient prefers surgery
types II, III, and IV
- Angina pectoris
- Gastroesophageal reflux disease (GERD)
- Informed consent for GI endoscopic procedures
- Adverse events associated with EGD and EGD-related techniques
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