Hiatus Hernia

Question 1

A hiatus hernia (HH) refers to when the there is a protrusion of part of the stomach through the diaphragmatic hiatus into the thoracic cavity. Which of the following is NOT an inherent risk factor for HH?

1 - Age
2 - Gender
3 - Lifestyle
4 - Genetics

Answer 1

3 - Lifestyle
This is an acquired risk factor

• Age = HH increase with age
• Gender = more likely in women

Question 2

Which of the following is NOT an acquired risk factor for a Hiatus hernia?

1 - Iatrogenic
2 - Mechanical stressor
3 - Lifestyle
4 - Genetics

Answer 2

4 - Genetics
This is an inherent risk factor

• Lifestyle factors = Obesity and smoking
• Mechanical stressors = heavy lifting and activity that increases intra-abdominal 0 Surgery = manipulation or disruption of the gastroesophageal junction can result in a hiatal hernia.

Question 3

Which of the following mechanical features are important, and if damaged can cause a hiatus hernia?

1 - lower oesophageal sphincter (LOS)
2 - gastroesophageal junction
3 - esophageal hiatus
4 - phrenoesophageal ligaments
5 - all of the above

Answer 3

5 - all of the above

Question 4

There are 4 main types of hiatus hernia (HH). Which of these matches the following description?

• rare accounts for 5% HH, the gastroesophageal junction is in normal position, but stomach herniates beside it. Increased risk of gastric volvulus and strangulation

1 - Pure Paraesophageal Hernia
2 - Complex or Giant Paraesophageal Hernia
3 - Sliding Hiatus Hernia
4 - Mixed Hiatus Hernia.

Answer 4

1 - Pure Paraesophageal Hernia

Classed as Type II

Question 5

There are 4 main types of hiatus hernia (HH). Which of these matches the following description?

• both the gastroesophageal junction and part of the stomach herniate through the esophageal hiatus. Accounts for 5% of HH and increases the risk of gastric volvulus and strangulation.

1 - Pure Paraesophageal Hernia
2 - Complex or Giant Paraesophageal Hernia
3 - Sliding Hiatus Hernia
4 - Mixed Hiatus Hernia

The most common type, accounting for more than 90% of cases. It involves a sliding movement of the gastroesophageal junction (GEJ) above the diaphragm alongside a portion of the stomach.
Clinically, it is often associated with gastroesophageal reflux disease (GERD).

Type IV: Complex or Giant Paraesophageal Hernia

Answer 5

4 - Mixed Hiatus Hernia

Classed as a type III HH

Question 6

There are 4 main types of hiatus hernia (HH). Which of these matches the following description?

• Involves herniation of other organs such as colon, spleen or small intestine along with a substantial portion of stomach through esophageal hiatus. Rare, but requires urgent surgical intervention due to high risk complications like strangulation and perforation.

1 - Pure Paraesophageal Hernia
2 - Complex or Giant Paraesophageal Hernia
3 - Sliding Hiatus Hernia
4 - Mixed Hiatus Hernia

Answer 6

2 - Complex or Giant Paraesophageal Hernia

Classed as a type IV HH

Question 7

There are 4 main types of hiatus hernia (HH). Which of these matches the following description?

• most common type, accounts for >90% of cases. Involves a sliding movement of the gastroesophageal junction (GEJ) above the diaphragm alongside a portion of the stomach. Clinically, it is often associated with gastroesophageal reflux disease (GERD).

1 - Pure Paraesophageal Hernia
2 - Complex or Giant Paraesophageal Hernia
3 - Sliding Hiatus Hernia
4 - Mixed Hiatus Hernia

Answer 7

3 - Sliding Hiatus Hernia

Classed as a type I HH

Question 8

All of the following are common clinical features of a hiatus hernia, but which is by far the most common feature?

1 - Gastro-oesophageal Reflux
2 - Chest Pain
3 - Respiratory Symptoms
4 - Anaemia
5 - Dyspepsia
6 - Oesophagitis

Answer 8

1 - Gastro-oesophageal Reflux

• Chest Pain = similar to angina, and worse when lying down or bending over
• Respiratory Symptoms = reduced thoracic space for breathing
• Anaemia - small volume of chronic bleeding
• Dyspepsia - stomach ache
• Oesophagitis = continued reflux can lead to inflammation

Question 9

Do all patients with a hiatus hernia (HH) present with symptoms?

Answer 9

• No

HH may be found on random testing for something else

Question 10

Management of a hiatus hernia can be divided into:

Lifestyle modifications
- Reduce food and drink that exacerbate symptoms
- Weight loss reduces intra-abdominal pressure
- Bed elevation
- Smoking cessation

Medical management
- PPI are first-line therapy for symptomatic relief and healing esophagitis in patients with associated GERD.
- H2 receptor antagonists may be considered if PPIs are not tolerated or contraindicated.
- Prokinetic agents may help with motility disorders

Surgical management
- Laparoscopic fundoplication is the procedure of choice f
- Hernia repair with mesh may be considered in large paraesophageal hernias to reduce the risk of recurrence.
- Emergency surgery is indicated for complications such as strangulation or perforation.

Answer 10

Treatment is ultimately decided based on the:

• patients symptoms
• patients comorbidities and risk factors
• severity of the HH

Question 10

Diagnosis is a combination of history, examination and investigations. What is thew 1st line test for diagnosing a hiatus hernia (HH)?

1 - chest X-ray
2 - endoscopy
3 - barium swallow
4 - gastroscopy
5 - pH Monitoring
6 - High Resolution Manometry (HRM) and Impedance-pH Monitoring

Answer 10

3 - barium swallow
Gives information about the size, type and any associated complications of the HH

BUT gastroscopy is GOLD standard

pH Monitoring = GORD
High Resolution Manometry (HRM) and Impedance-pH Monitoring = used if diagnosis is inconclusive