Upper GI & Hepatobiliary Surgery

Hiatus Hernia

A hiatus hernia is upward displacement of stomach through the oesophageal hiatus; sliding hernia can impair the reflux barrier, while para-oesophageal or mixed hernia can cause early satiety, bleeding, obstruction or volvulus, so treatment is driven by symptoms, complications, anatomy and operative risk.

In a nutshell

Most hiatus hernias are sliding and may be incidental or associated with GORD. Paraoesophageal or mixed hernias can cause postprandial mechanical symptoms, Cameron-lesion bleeding or acute volvulus. Treat reflux with lifestyle measures and PPI-based care; arrange specialist assessment for persistent symptoms or symptomatic/complicated paraoesophageal disease, and escalate acute obstruction or strangulation urgently.

Classic presentation

Heartburn and regurgitation in sliding hernia, or postprandial fullness, early satiety, dysphagia, chest/epigastric pain or iron-deficiency anaemia in paraoesophageal or mixed hernia.

Key points

Type 1 sliding hernia moves the gastro-oesophageal junction; type 2 paraoesophageal hernia leaves the junction below the diaphragm while stomach herniates alongside it; type 3 combines both.
A sliding hernia can worsen the reflux barrier, but not every hiatus hernia causes GORD and not every symptom is caused by the hernia.
Paraoesophageal or mixed hernia can cause pain, early satiety, dysphagia, chronic bleeding from Cameron lesions, obstruction or volvulus.
OGD assesses mucosa and the junction; barium imaging clarifies anatomy; CT is urgent when obstruction, volvulus or ischaemia is suspected; physiology testing supports surgical reflux decisions.
NICE recommends PPI-based GORD care and specialist referral when symptoms are unexplained, non-responsive or surgery is being considered.
Do not state that every asymptomatic paraoesophageal hernia automatically needs repair; specialist assessment should weigh symptoms, anatomy, frailty and operative risk.
Severe pain with retching and inability to vomit, persistent vomiting, haematemesis, shock or peritonism is an emergency, not uncomplicated reflux.

First-line investigation

Clinical assessment and, when persistent, unexplained or alarm symptoms are present, OGD; use barium imaging, CT and oesophageal physiology selectively.

Management

Identify obstruction or strangulation

Severe chest or epigastric pain with retching, inability to vomit, persistent vomiting, haematemesis, shock or peritonism requires nil by mouth, resuscitation, urgent imaging and upper-GI surgical escalation.^2,1

Define symptoms and anatomy

Separate incidental hernia from reflux or mechanical symptoms; use OGD for mucosal assessment, barium imaging for anatomy and CT when complex or acute disease is suspected.^1,3,2

Control reflux and protect nutrition

Use individualised meal, weight, smoking, trigger and head-of-bed advice; offer NICE PPI-based treatment and assess anaemia, vomiting, intake and weight when paraoesophageal disease is suspected.^3,2,1

Refer for tailored surgical decision-making

Confirm reflux and assess motility before anti-reflux surgery; refer symptomatic or complicated paraoesophageal/mixed hernia for specialist repair discussion, without making automatic surgery the rule for every asymptomatic case.^3,4,1

Safety-net symptoms and postoperative effects

Review persistent dysphagia, reflux, vomiting, bleeding, weight loss or recurrent pain; after repair, provide diet progression and safety-net advice for inability to eat or drink, severe pain, fever or wound problems.^2,7

Exam traps

Sliding and paraoesophageal hernias are not interchangeable: the former is reflux-predominant, while the latter is primarily a mechanical-risk problem.
Borchardt-type symptoms should trigger urgent surgical assessment and imaging rather than more antacid or PPI treatment.
A hiatus hernia on OGD does not by itself prove pathological reflux; confirm reflux and assess motility before anti-reflux surgery.
Do not turn a historical blanket rule for elective repair of all paraoesophageal hernias into current practice; management is individualised, especially in frail or asymptomatic people.
Cameron lesions can be missed unless the hernia and diaphragmatic pinch are carefully inspected, including in retroflexion.

Illustrations

Sliding versus paraoesophageal hiatus herniaDiagram contrasting a sliding hernia, where the gastro-oesophageal junction moves above the diaphragm, with a paraoesophageal hernia, where the fundus herniates alongside a normally positioned junction.Mysid, Wikimedia Commons · CC0

Sliding hiatus hernia on retroflexed endoscopyRetroflexed endoscopic view showing a widened diaphragmatic hiatus around the endoscope in a type I sliding hiatus hernia; incidental fundic gland polyps are also present.Samir, Wikimedia Commons · CC-BY-SA-4.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.