🪑 Hiatus hernia occurs when part of the stomach pushes through the diaphragm into the chest cavity. Often silent 🤫, but it may cause reflux 🔥 (GORD) and long-term complications. Early recognition + treatment are key to preventing oesophageal damage.

📖 About Hiatus Hernia

Hiatus hernia = stomach protrusion through the oesophageal hiatus of the diaphragm. Two main types:

➡️ Sliding (95%): Gastro-oesophageal junction + stomach slide into thorax.
➡️ Paraesophageal: Part of stomach herniates beside oesophagus → risk of strangulation ⚠️.

Weakened diaphragmatic sphincter.
Lower oesophagus + stomach rise into thorax.
Common anatomical variation affecting digestion 🍽️.

⚙️ Aetiology

🔥 Chronic GORD: Weakens diaphragm over time.
⚖️ Obesity: Increases intra-abdominal pressure.
📆 Age: Tissue weakening with age.
🧬 Genetics: Familial tendency.
🤰 Pregnancy: Raised intra-abdominal pressure.
🤕 Trauma: Abdominal injury weakening diaphragm.

👩‍⚕️ Clinical Presentation

🤫 Asymptomatic: Commonly found incidentally.
🔥 Reflux symptoms: Heartburn, regurgitation, sour taste.
❤️ Chest pain: May mimic angina → rule out cardiac causes.
🥴 Dysphagia: Red flag 🚨 → consider malignancy.
💨 Belching/bloating: Excessive gas + discomfort.
🎤 Hoarseness/sore throat: Reflux affecting vocal cords.

💡 Clinical Pearl: Hiatus hernia can mimic angina ❤️. Always exclude cardiac disease in chest pain patients. Dysphagia + weight loss ⚠️ → think oesophageal cancer, not just reflux.

🧾 Differential Diagnosis

🔥 GORD without hernia
❤️ Angina pectoris (ischaemic chest pain)
🦠 Oesophageal cancer
🌀 Achalasia (motility disorder)
🩹 Peptic ulcer disease
⚠️ Hiatal abscess (rare)

🔎 Investigations

🩸 Bloods: FBC (anaemia from bleeding), U&E, LFTs.
🖼️ Barium swallow: Visualises herniation + function.
📡 OGD (endoscopy): Detect oesophagitis, Barrett’s, malignancy.
🩻 CXR: Retrocardiac mass clue.
📏 Manometry: Assesses motility if dysphagia.
📊 24h pH monitoring: Quantifies reflux.

🛠️ Management

🏃 Lifestyle: Weight loss, avoid late meals, smaller portions, elevate bedhead, avoid trigger foods (coffee, alcohol, chocolate, spicy foods).
💊 Pharmacological:
- Antacids → quick relief.
- PPIs / H2 blockers → reduce acid.
- Prokinetics → improve emptying.
🔧 Endoscopic therapy: Endoscopic fundoplication in selected cases.
🔪 Surgery: For refractory or complicated hernia (Nissen fundoplication, hiatoplasty, laparoscopic repair).

📚 Case Example

👩 A 58-year-old overweight woman (BMI 32) presents with 6 months of heartburn 🔥, worse at night, with occasional chest pain ❤️. She worries about her heart, but ECG is normal. OGD shows erosive oesophagitis and a sliding hiatus hernia. ✅ Management: Lifestyle advice (weight loss, avoid late meals), PPI therapy, follow-up. Surgery considered only if refractory or complications develop.

🌟 Prognosis

✅ Asymptomatic: Often requires no treatment.
🔥 Symptomatic: Controlled well with PPIs + lifestyle.
⚠️ Complicated: Surgery needed for strangulation or severe reflux damage.
📅 Follow-up: Long-term to monitor for Barrett’s oesophagus or malignancy risk.

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Hiatus hernia