πͺ Hiatus hernia occurs when part of the stomach pushes through the diaphragm into the chest cavity.
Often silent π€«, but it may cause reflux π₯ (GORD) and long-term complications.
Early recognition + treatment are key to preventing oesophageal damage.
π About Hiatus Hernia
Hiatus hernia = stomach protrusion through the oesophageal hiatus of the diaphragm.
Two main types:
- β‘οΈ Sliding (95%): Gastro-oesophageal junction + stomach slide into thorax.
- β‘οΈ Paraesophageal: Part of stomach herniates beside oesophagus β risk of strangulation β οΈ.
- Weakened diaphragmatic sphincter.
- Lower oesophagus + stomach rise into thorax.
- Common anatomical variation affecting digestion π½οΈ.
βοΈ Aetiology
- π₯ Chronic GORD: Weakens diaphragm over time.
- βοΈ Obesity: Increases intra-abdominal pressure.
- π Age: Tissue weakening with age.
- 𧬠Genetics: Familial tendency.
- π€° Pregnancy: Raised intra-abdominal pressure.
- π€ Trauma: Abdominal injury weakening diaphragm.
π©ββοΈ Clinical Presentation
- π€« Asymptomatic: Commonly found incidentally.
- π₯ Reflux symptoms: Heartburn, regurgitation, sour taste.
- β€οΈ Chest pain: May mimic angina β rule out cardiac causes.
- π₯΄ Dysphagia: Red flag π¨ β consider malignancy.
- π¨ Belching/bloating: Excessive gas + discomfort.
- π€ Hoarseness/sore throat: Reflux affecting vocal cords.
π‘ Clinical Pearl:
Hiatus hernia can mimic **angina** β€οΈ. Always exclude cardiac disease in chest pain patients.
Dysphagia + weight loss β οΈ β think oesophageal cancer, not just reflux.
π§Ύ Differential Diagnosis
- π₯ GORD without hernia
- β€οΈ Angina pectoris (ischaemic chest pain)
- π¦ Oesophageal cancer
- π Achalasia (motility disorder)
- π©Ή Peptic ulcer disease
- β οΈ Hiatal abscess (rare)
π Investigations
- π©Έ Bloods: FBC (anaemia from bleeding), U&E, LFTs.
- πΌοΈ Barium swallow: Visualises herniation + function.
- π‘ OGD (endoscopy): Detect oesophagitis, Barrettβs, malignancy.
- π©» CXR: Retrocardiac mass clue.
- π Manometry: Assesses motility if dysphagia.
- π 24h pH monitoring: Quantifies reflux.
π οΈ Management
- π Lifestyle: Weight loss, avoid late meals, smaller portions, elevate bedhead, avoid trigger foods (coffee, alcohol, chocolate, spicy foods).
- π Pharmacological:
- Antacids β quick relief.
- PPIs / H2 blockers β reduce acid.
- Prokinetics β improve emptying.
- π§ Endoscopic therapy: Endoscopic fundoplication in selected cases.
- πͺ Surgery: For refractory or complicated hernia (Nissen fundoplication, hiatoplasty, laparoscopic repair).
π Case Example
π© A 58-year-old overweight woman (BMI 32) presents with 6 months of heartburn π₯, worse at night, with occasional chest pain β€οΈ.
She worries about her heart, but ECG is normal.
OGD shows erosive oesophagitis and a sliding hiatus hernia.
β
Management: Lifestyle advice (weight loss, avoid late meals), PPI therapy, follow-up.
Surgery considered only if refractory or complications develop.
π Prognosis
- β
Asymptomatic: Often requires no treatment.
- π₯ Symptomatic: Controlled well with PPIs + lifestyle.
- β οΈ Complicated: Surgery needed for strangulation or severe reflux damage.
- π
Follow-up: Long-term to monitor for Barrettβs oesophagus or malignancy risk.