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Hiatal Hernia

  1. Congenitally short esophagus (not a true hernia) Associated with: diverticulosis (25%); Gallstones (18%); esophagitis (25%); Duodenal ulcer (20%) (Saint’s triad: Hiatus hernia + diverticulosis + Gall stones)Q


Type I: Sliding herniaQ (most common type – 70-80%)

Type II: Paraesophageal or rolling hernia

Type III: Mixed

Type IV: these hernias are distinguished by the presence of other abdominal viscera within the defect i.e. omentum, transverse colon.

  1. Type I or Sliding hiatal hernia This is characterized by upward dislocation of the cardioesophageal junction in to posterior mediastinum.
  2. Type II or rolling paraesophageal hernia
    1. The cardioeophageal junction is undisplaced
    2. The whole or part of stomach herniates into the thorax immediately adjacent and to the left of the undisplaced cardioesophageal junction.
  3. ​​Since the normally located gastroesophageal junction functions normally in most of these hernias, reflux is uncommon.  The combined sliding-rolling or mixed hernia, type III, characterized by an upward dislocation of both the cardia and the gastric fundus. The end stage of type I and type II hernias occurs when the whole stomach migrates up into the chest by rotating 180 degree around its longitudinal axis, with the cardia and pylorus as fixed points. In this situation the abnormality is usually referred to as an intrathoracic stomach.



Description: hiatal%20hernia


Sliding hernia

  1. “Axial hernia” concentric hernia 99%.Q
  2. Portion of peritoneal sac forms part of wall of hernia, gastroesophageal junction and a
  3. portion of the stomach are above the diaphragm.
  4. Cardia goes through hiatus, esophagus not always short and peritoneal sac not goes
  5. with paraesophageal hernia. (PGI June 99)
  6. Incidence: increases with age Etiology: repetitive upward stretching of phrenicoesophageal
  7. membrane. 
  • Findings:
  1. Barium meal – most useful investigation sliding and paraesophageal hernia. (UP PGMEE 08)
  2. UGI: Epiphrenic bulge/ distance between B ring and hiatal margin > 2cm/ tortuous esophagus/ gastroesophageal reflux/ 6 thick gastric folds within suprahiatal pouch
  3. CT: Dehiscence of diaphragmtic crura > 15 mm/ pseudomass within/above distal esophagus/ fat (omemtum) surrounding distal esophagus
  • Paraesophageal hiatal hernia
  1. "Rolling hiatal hernia," "parahiatal hernia"
  2. 1% of hiatal hernias. portion of stomach superiorly displaced into the thorax with the
  3. esophagogastric junction remaining in the subdiaphragmatic position
  4. Para esophageal type is uncommon type but more complicated so need surgical
  5. treatment in all symptomatic cases. (PGI June 08) 
  1. ​Findings:
    1. The gastroesophageal junction is in the normal location, but a portion of the stomach is adjacent to the esophagus i.e. cardia in normal position
    2. Herniation of portion of the stomach anterior to esophagus
    3. Frequently nonreducible, may be associated with gastric ulcer of lesser curvature at level of diaphragmatic hiatus 
  2. Symptoms and Signs
    1. Most patients are asymptomatic, but chest pain can occur.
    2. GERD occurs in few patients. A paraesophageal hiatus hernia is generally asymptomatic but, may incarcerate and strangulate.
    3. Occult or massive GI hemorrhage may occur with either type.
  3. Diagnosis and Treatment
    1. X-rays usually readily show hiatus hernia.
    2. A barium study helps distinguish a sliding from a paraesophageal hernia.
    3. Typical findings include an outpouching of barium at the lower end of the esophagus, a wide hiatus through which gastric folds are seen in continuum with those in the stomach, and, occasionally, free reflux of barium. 
  4. Endoscopy
    1. Hiatal hernia is diagnosed easily using upper gastrointestinal endoscopy.Q
    2. A hiatal hernia is confirmed when the endoscope is about to enter the stomach or on retrograde view once inside the stomach.
    3. Endoscopy also permits biopsy of any abnormal or suspicious area. 
  5. Treatment:
    1. Self-care action plan
      1. Modifying lifestyle factors/ Neutralizing acid or inhibiting acid production/ Enhancing esophageal and gastric motility
      2. Surgery: Surgery is necessary only in the minority of patients with complications of GERD despite aggressive treatment with proton pump inhibitors (PPIs). The rolling hernia may strangulate and frequently is operated on prophylactically to prevent this.  
    2. Nissen fundoplication
      1. This procedure involves a 360° fundic wrap around the gastroesophageal junction. The diaphragmatic hiatus also is repaired.
      2. It can be performed laparoscopically. Postoperative complications are dysphagia and gas bloating.
      3. The Toupet procedure is a variant of the Nissen wrap and involves a 180° wrap in an attempt to lessen the likelihood of postoperative dysphagia. (Surgical option of choice)Q
      4. Belsey (mark IV) fundoplication: This operation involves a 270° wrap.
      5. It also is preferred when minimal esophageal dysmotility is suspected.
      6. To complete this operation, the left and right crura of the diaphragm are approximated.
      7. Hill repair: In this procedure, the cardia of the stomach is anchored to the posterior abdominal areas,  such as the medial arcuate ligament.
      8. This also has the effect of augmenting the angle of His and thus strengthening the antireflux mechanism. 
  1. Boerhaave Syndrome
    1. Boerhaave syndrome is a spontaneous transmural perforation (UP PGEE 07) of the esophagus resulting from a sudden rise in intraluminal pressure caused by an uncoordinated act of forceful vomiting against a closed cricopharyngeal sphincter
    2. More than 90% of these perforations occur in the left posterolateral wall of the lower third of the sophagus.Q
      1. ​​​​The syndrome can also occur after other spontaneous Valsalva-like maneuvers, such as Childbirth, Coughing, Straining during a bowel movement, or Heavy lifting.
  2. Nonspontaneous causes include
    1. Iatrogenic perforation associated with endoscopy, - Most common cause (PGI 87)
    2. Ingestion of a caustic substance, and Blunt trauma to the neck and chest.
  • Physical Examination & Signs

  1. Often non specific
  2. Subcutaneous emphysema in neck or chest in up 60%.
  3. Chest pain, tachypnea & tachycardia common initial physical finding but fever may not be present for hours  to days. (UP PGMEE 2007)
  4. “Mackler Triad” consisting   of vomiting, chest pain, & subcutaneous emphysema is associated with spontaneous esophageal perforation is only fully present in about 50% of cases.
  5. Hamman sign Q  raspy, crunching sound heard over precardium with each heart beat caused by mediastinal emphysema.
  6. After repeated episodes of retching and vomiting patient feels a Sudden onset of severe chest pain in the lower thorax and upper abdomen. The pain typically radiates to the back or left shoulder as a result of the intense inflammatory response to the saliva and gastric contents entering the mediastinum.
  7. Other symptoms are neck pain, dysphagia, odynophagia, respiratory distress, and fever. On physical examination, nonspecific findings may be present: tachycardia, diaphoresis, fever, hypotension, and generalized abdominal tenderness with guarding and rebound.
  8. The diagnosis is established by means of water-soluble contrast esophagraphy to reveal the location and extent of extravasation. It is the intial study of choice.Q
  9. Most sensitive for detective small perforation is Barium Study Q, should be performed with patient in right lateral decubitus position. (Chances of Severe mediastinitis)  
  10. Chest radiograph classically shows “V” sign & it is indicative of pneumo mediastinum. Q Air outlines the left lower mediastinal border & medial left hemidiaphragm forming a “V”.  
  11. Endoscopy has a limited role, as small tears are difficult to visualize on this study. In addition, the insufflation of air required for the procedure can result in the extension of the perforation. Prompt diagnosis and early surgical intervention is crucial.
  12. Management includes strict adherence to giving the patient nothing by mouth, administration of broad- spectrum antibiotics, fluid resuscitation, nasogastric decompression, and early consultation with a surgeon. Depending on the location of the tear, a chest or abdominal approach to repair the perforation is performed,  and parenteral nutrition is required.
  13. Surgical Management: If patient present within 12 hrs of perforation treatment is primary repair of perforation but if more than 12 hrs have elapsed treatment is by esophageal exclusion.
Management of options in perforation of the esophagus
Factors that favour non-operative management Factors that favour operative repair
Small septic load
Minimal cardiovascular upset
Perforation confined to mediastinum
Perforation by flexible endoscope
Perforation of cervical oesophagus
Large septic load
Septic shock
Pleura breached
Boerhave’s syndrome
Perforation of abdominal oesophagus
  1. Early recognition followed by prompt surgery remains the treatment of choice for this life-threatening thoracic emergency.
  2. Since the perforation is usually on the left side of the lower esophagus, the lesion can be visualized through a left-sided thoracotomy.
  3. After the esophageal tear is identified, it should be closed and then reinforced with a patch of adjacent  tissue. External drainage of the chest completes the procedure.

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