Complications of Hiatal HerniasComplications of Hiatal Hernias

Krista Fajman, M.D.Krista Fajman, M.D.

September 23, 2009September 23, 2009

Hiatal HerniasHiatal Hernias Herniation of organs of the Herniation of organs of the

abdomen into the thoracic cavity abdomen into the thoracic cavity through the esophageal hiatus at through the esophageal hiatus at the diaphragmthe diaphragm

Weakening of the diaphragmatic Weakening of the diaphragmatic hiatus thought to be caused by hiatus thought to be caused by repetitive stress of swallowing, repetitive stress of swallowing, abdominal straining, vomiting in abdominal straining, vomiting in addition to contraction of the addition to contraction of the esophageal longitudinal muscle esophageal longitudinal muscle induced by reflux and induced by reflux and acidification of the mucosa.acidification of the mucosa.

ClassificationClassification Type I (Sliding Hiatal Hernia)Type I (Sliding Hiatal Hernia)

> 95% of cases, increasing > 95% of cases, increasing incidence with ageincidence with age

Hiatus widens and Hiatus widens and phrenoesophageal membrane phrenoesophageal membrane loosens loosens gastroesophageal gastroesophageal junction and fundus of the stomach junction and fundus of the stomach displaced above the diaphragm. displaced above the diaphragm.

Hernia contained within the Hernia contained within the posterior mediastinum.posterior mediastinum.

Diagnose with barium swallow or Diagnose with barium swallow or endoscopy if > 2 cm. Esophageal endoscopy if > 2 cm. Esophageal manometry can diagnose smaller manometry can diagnose smaller hernias. hernias.

Classification continuedClassification continued Types II, III, IV (Paraesophageal Hernia)Types II, III, IV (Paraesophageal Hernia)

Type II – GE junction fixed. Type II – GE junction fixed. Progressive enlargement of the hiatusProgressive enlargement of the hiatus

Type III (Mixed Hernia) – Type III (Mixed Hernia) – Enlargement of the hiatal hernia, Enlargement of the hiatal hernia, displacement of the lower esophageal displacement of the lower esophageal sphincter and gastric fundus above the sphincter and gastric fundus above the diaphragmdiaphragm

Type IV – Associated with herniation Type IV – Associated with herniation of the colon, spleen, pancreas, and of the colon, spleen, pancreas, and small intestinesmall intestine

5-10% of hernias. 5-10% of hernias. Unclear etiology but associated with Unclear etiology but associated with

weakening of the gastrosplenic and weakening of the gastrosplenic and gastrocolic ligaments. gastrocolic ligaments.

Best diagnosed with barium swallow Best diagnosed with barium swallow although can usually be seen on although can usually be seen on endoscopy. CT or MRI helpful if you endoscopy. CT or MRI helpful if you suspect herniation of organs other than suspect herniation of organs other than the stomach.the stomach.

ImagingImaging

SymptomsSymptoms May be asymptomaticMay be asymptomatic RefluxReflux Chest, epigastric or substernal painChest, epigastric or substernal pain DysphagiaDysphagia Postprandial fullnessPostprandial fullness Nausea, vomitingNausea, vomiting GastritisGastritis Chronic blood loss from gastric ulceration or erosions Chronic blood loss from gastric ulceration or erosions

within the herniawithin the hernia Respiratory complicationsRespiratory complications

Hiatal Hernia TreatmentHiatal Hernia Treatment Repair of asymptomatic type I hernias rarely require surgical repair. If pt Repair of asymptomatic type I hernias rarely require surgical repair. If pt

has GERD, medical or surgical treatment is indicated to control the reflux.has GERD, medical or surgical treatment is indicated to control the reflux. Types II, III, and IV – Even if asymptomatic, imposes a certain risk on the Types II, III, and IV – Even if asymptomatic, imposes a certain risk on the

patient. patient. Never regress although may enlarge.Never regress although may enlarge. Can result in herniation of the stomach or other abdominal organs into Can result in herniation of the stomach or other abdominal organs into

the thorax.the thorax. If untreated can pose a risk of serious complications. If untreated can pose a risk of serious complications.

Nonoperative mortality rate = as high as 80% Nonoperative mortality rate = as high as 80% Mortality rate from acute gastric volvulus = 15-20% Mortality rate from acute gastric volvulus = 15-20% Mortality rate from chronic gastric volvulus ranges up to 13%Mortality rate from chronic gastric volvulus ranges up to 13%

Once identified Once identified treat surgically. treat surgically.

Gastroesophageal RefluxGastroesophageal Reflux Estimated prevalence of 14-20% in the general populationEstimated prevalence of 14-20% in the general population Diagnose with endoscopy Diagnose with endoscopy rule out Barrett’s, rule out Barrett’s,

adenocarcinoma, ulcers. Also consider adenocarcinoma, ulcers. Also consider H. pyloriH. pylori, manometry, manometry

First line treatment – Lifestyle modification, Antacids, H2 First line treatment – Lifestyle modification, Antacids, H2 blockers and PPIsblockers and PPIs

Complications of chronic PPI use:Complications of chronic PPI use: Increased risk of hip fracture in pts > 50 years oldIncreased risk of hip fracture in pts > 50 years old Increased risk of infectious gastroenteritisIncreased risk of infectious gastroenteritis Increased risk of Increased risk of C. difficileC. difficile colitis colitis Decreased effectiveness of PlavixDecreased effectiveness of Plavix

Treatment for refractory GERD Treatment for refractory GERD associated with herniasassociated with hernias

Consider TCAs in those that do not Consider TCAs in those that do not respondrespond

Fundoplication - the proximal Fundoplication - the proximal stomach is wrapped around the LES stomach is wrapped around the LES increased LES pressure. increased LES pressure.

Surgical risks include frequent need for revision, dysphagia, flatulence, difficulty belching, bloating, abdominal pain, diarrhea, constipation.

No difference in rates of Barrett’s No difference in rates of Barrett’s metaplasia or adenocarcinoma metaplasia or adenocarcinoma between medical or surgical between medical or surgical management. management.

Gastric VolvulusGastric Volvulus

Uncommon, although most common complication Uncommon, although most common complication of paraesophageal hernias. of paraesophageal hernias.

Paraesophageal hernias progressively enlarge Paraesophageal hernias progressively enlarge eventually the stomach herniates through the eventually the stomach herniates through the hiatus forming an upside down stomach in the hiatus forming an upside down stomach in the thoracic cavity.thoracic cavity.

Associated with dysphagia or postprandial pain. Associated with dysphagia or postprandial pain. Twisting of up to 180 degrees may cause no Twisting of up to 180 degrees may cause no

obstructionobstruction

Gastric VolvulusGastric Volvulus OrganoaxialOrganoaxial

Most commonMost common Associated with Associated with

diaphragmatic defectsdiaphragmatic defects Vascular compromise Vascular compromise

commoncommon

Mesenteric AxisMesenteric Axis Chronic symptoms more Chronic symptoms more

commoncommon Diaphragmatic defect less Diaphragmatic defect less

commoncommon

Imaging of Gastric Volvulus

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