Hiatus Hernia

This is where there's herniation of the stomach up through diaphragm. The diaphragmatic opening is at the level of the lower oesophageal sphincter (LOS), which stops acid and stomach contents refluxing back into the oesophagus. When this is compromised, the acid and contents can reflux back up. There are 2 types of this:

• Sliding (80%) – Junction slides up into the chest. Sphincter becoming less competent results in acid reflux. Treatment is similar to that of GORD.

• Rolling (20%) – Junction remains in the abdomen, but part of the stomach protrudes into the chest alongside the oesophagus. This type requires more urgent treatment as volvulus can occur, resulting in ischaemia and necrosis.

Risk factors - Age (Muscle weakening and loss of elasticity), Obesity, Previous hiatal surgery, Increased intra-abdominal pressure (Pregnancy, Ascites, Chronic cough)

Patients present with:

• Heartburn

• Dysphagia/odynophagia

• SOB

• Chronic cough

• Halitosis (bad breath)

The main investigations to do include a CXR or Barium swallow. Other investigations may be Endoscopy and CT.

Management:

Conservative - Weight loss, avoid large meals before bed, avoid alcohol and acidic foods

Medical - PPI

Surgical - Laparoscopic (Nissen’s) Fundoplication