Case of the Week - Patient Summary 10247Peer Reviewed and Certified -
Axial (sliding) hiatal hernia Patients with paraesophageal and mixed hiatal hernias are rarely completely asymptomatic if closely questioned. About half of patients with paraesophageal hernias have gastroesophageal reflux. Other symptoms include dysphagia, chest pain, vague postprandial discomfort, and shortness of breath. A substantial number of patients have chronic gastrointestinal blood loss. If the hernia is complicated by gastric volvulus, acute abdominal pain and retching will occur, often progressing rapidly to a surgical emergency. A paraesophageal or mixed hiatal hernia may be seen on chest radiograph as an abnormal soft tissue density (often with a gas bubble) in the mediastinum. Upper gastrointestinal radiograph is the best diagnostic study. [1]
Hiatal hernias are occasionally complicated by volvulus. The stomach is normally fixed in position by ligamentous attachments to the duodenum, spleen, liver, and diaphragm. Laxity of these ligaments, elevation of the left hemidiaphragm, adhesions, gastric tumor, or masses in adjacent organs may predispose to volvulus. In about one third of cases the volvulus occurs below the diaphragm. In the other two thirds of cases volvulus occurs above the diaphragm in association with a diaphragmatic hernia. Sliding hiatal hernias are not associated with gastric volvulus. Gastric volvulus may be mesenteroaxial or organoaxial. In about 60% of cases gastric volvulus is organoaxial: the stomach twists along its long axis. This axis usually passes through the gastroesophageal and gastropyloric junctions. The antrum rotates anteriorly and superiorly, the fundus posteriorly and inferiorly, twisting the greater curvature at some point along its length. This type of volvulus is commonly associated with a diaphragmatic hernia. Organoaxial volvulus is usually an acute event. Vascular compromise and gastric infarction may occur. The other major type of gastric volvulus is mesenteroaxial, in which the stomach folds on its short axis running across from the lesser curvature to the greater curvature, and the antrum twists anteriorly and superiorly. [1]
Simple sliding hiatal hernias do not require treatment. Patients with symptomatic giant sliding hiatal hernias, paraesophageal, and mixed hernias should be offered surgery. Many experts suggest that surgery should be offered to patients with asymptomatic paraesophageal hernias, because about 30% of these patients will develop complications if left untreated. Many surgeons routinely perform a fundoplication on all repairs, both to prevent postoperative reflux esophagitis and to fix the stomach in the abdomen. Less commonly a gastrostomy is used to fix the stomach in position. Patients with sliding hiatal or paraesophageal hernias may have shortening of the esophagus. This makes it ...
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