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  • • Often asymptomatic

    • Symptoms of mechanical obstruction include:

    • -Dysphagia

      -Incarceration

      -Stasis gastric ulcer

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Epidemiology

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  • • Acquired diaphragmatic defect containing variable amounts of stomach with or without other abdominal viscera

    • Type II: Rolling; upper dislocation of fundus of the stomach alongside a normally positioned intra-abdominal gastroesophageal junction (GEJ)

    • -Since the GEJ functions normally in type II hernias, reflux is uncommon

    • Type III: Mixed; upper displacement of the fundus and the GEJ

    • Type IV: Hernia contains other abdominal vicera (colon, small intestine)

    • Herniation caused by combined effects of age, stress, and other degenerative factors on the diaphragm

    • Always at risk for strangulation, necrosis or gastric perforation

    • Type III more common than type II

    • More common in women than in men; incidence increases with age

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Symptoms and Signs

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  • • Often asymptomatic

    • Pain or pressure in the lower chest after eating

    • Vomiting

    • Early satiety

    • Hematemesis

    • Dyspnea and pain on inspiration

    • Decreased breath sounds in the left chest

    • Bowel sounds in the left chest

    • Palpitations due to cardiac dysrhythmias

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Laboratory Findings

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  • • Anemia in 30% of patients

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Imaging Findings

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  • Chest film: Gastric air-fluid level behind cardiac shadow

    Upper GI contrast radiography: Cephalad displacement of the stomach and possibly other abdominal viscera above the diaphragm

    Endoscopy: On retroversion, orifice of the herniated portion of the stomach adjacent to the GEJ (type II) or pouch with gastric rugal folds above the diaphragm with GEJ entering side of pouch (type III)

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  • • Preoperative manometry or pH testing is unreliable predictor of true reflux since distorted anatomy may give rise to abnormal findings that may be corrected by reduction of hernia

    • Upper GI contrast radiography most reliable means of diagnosis

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Rule Out

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  • • Gastric volvulus

    • Strangulated viscera

    • Gastric necrosis

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  • • Upper GI contrast radiography

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When to Admit

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  • • Suspected strangulation

    • Upper GI bleeding

    • Complete gastric obstruction

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Surgery

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  • • The herniated viscera is returned to the abdomen and the enlarged hiatus is closed snugly around the GEJ

    • A fundoplication may be performed to anchor the stomach or prevent reflux

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Indications

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  • • Since complications are frequent even in the absence of symptoms, operative repair is indicated

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Complications

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  • • Upper GI hemorrhage

    • Incarceration

    • Obstruction

    • Strangulation

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Prognosis

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  • • Excellent

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References

Aly A et al: Laparoscopic repair of larger hiatal hernias. Br J Surg 2005;92:648.  [PubMed: 15800954]
Oelschlager BK et al: Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair. A multicenter, prospective, randomized trial. Ann ...

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