Discussion Author(s): Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., Copyright © 2002 Elsevier: MD Consult Online Core Collection Textbook: pp 369-374
In the United States and Canada, a large proportion of adults undergoing upper gastrointestinal barium radiographs are found to have a small hiatal hernia. About 90% to 95% of hiatal hernias found by radiograph are sliding hernias, and the rest are paraesophageal or mixed. Most sliding hiatal hernias are small and of little clinical significance. Patients with symptomatic paraesophageal hernias are most often middle-aged to elderly. Many patients with small, simple sliding hiatal hernias are asymptomatic. The main clinical significance of the sliding hiatal hernia is its contribution to gastroesophageal reflux . In addition to heartburn and regurgitation, patients with large sliding hiatal hernias may complain of dysphagia or discomfort in the chest or upper abdomen. In a prospective, population-based study the risk of iron-deficiency anemia was found to be increased in adults with hiatal hernia. On chest radiograph a hiatal hernia may be noted as a soft tissue density in the retrocardiac area. Hiatal hernias are most often diagnosed on upper gastrointestinal barium radiographic studies. At endoscopy the gastroesophageal junction is noted to be proximal to the impression of the diaphragm. [1]
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 difficult to restore the gastroesophageal junction below the diaphragm without tension. In such cases an extra length of neoesophagus can be constructed from the proximal stomach (Colles-Nissen procedure). Paraesophageal and mixed hernias can be repaired through the chest or abdomen, with open or laparoscopic techniques. Compared with open repair, laparoscopic repair is associated with less blood loss, fewer overall complications, shorter hospital stay, and quicker return to normal activities. Long-term results are probably equal with either approach. Potential surgical complications include esophageal and gastric perforation, pneumothorax, and liver laceration. Potential long-term complications may include dysphagia if the wrap is too tight or gastroesophageal reflux if the fundoplication breaks down or migrates into the chest. Recurrence rates are about 10 [1]
1. Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed., Copyright © 2002 Elsevier: MD Consult Online Core Collection Textbook: pp 369-374
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