QuestionSBA
QuestionChoice
In the first instance, weight loss, avoiding large meals,avoiding acidic/spicy foods, avoiding caffeine/alcohol, and quitting smoking should be implemented along with a proton pump inhibitor or H2 blocker.
10015801
a
Lifestyle measures and symptomatic control
QuestionChoice
Urgent referral for surgical correction is only needed if the patient experiences acute complications such as severe chest pain or difficulty swallowing.
10015803
c
Urgent referral for surgical correction
QuestionChoice
Routine referral for surgical correction is not necessary unless the patient experiences chronic and severe symptoms, or develops complications such as bleeding, narrowing of the oesophagus, or a strangulated hernia.
10015802
b
Routine referral for surgical correction
QuestionChoice
Not addressing the patient's symptoms is not appropriate in this scenario.
10015804
d
Discharge with safety netting
QuestionChoice
There is no role for endoscopic surveillance for simple hiatus hernias. This may be required if a patient has concurrent pathology such as Barrett's oesophagus.
10015805
e
Refer for 6 monthly endoscopic monitoring
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# Summary

A hiatus hernia is a medical condition where abdominal contents protrude through an enlarged oesophageal hiatus in the diaphragm. There are two main types: sliding, which makes up 80% of cases and rolling, which makes up the remaining 20%. The condition is primarily diagnosed through barium swallows, endoscopy, and oesophageal manometry. Management strategies range from lifestyle changes to medication and surgery in severe cases. 

# Definition

A hiatus hernia is a medical condition that occurs when abdominal contents protrude through an enlarged oesophageal hiatus in the diaphragm.

# Epidemiology

The prevalence of hiatus hernia increases with age and is more common in individuals with certain risk factors.

Risk factors for hiatus hernia include:

- Obesity
- Prior hiatal surgery
- Increased intra-abdominal pressure, such as from chronic cough, multiparity, or ascites

# Aetiology

There are two main types of hiatus hernias:

1. **Sliding hiatal hernia** (80%): Here, the gastro-oesophageal junction slides up into the chest. This results in a less competent sphincter and consequent acid reflux. Treatment is similar to Gastroesophageal reflux disease (GORD).
2. **Rolling hiatal hernia** (20%): In this type, the gastro-oesophageal junction stays in the abdomen, but part of the stomach protrudes into the chest alongside the oesophagus. This type requires more urgent treatment since volvulus can lead to ischemia and necrosis.

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# Signs and Symptoms

Symptoms of a hiatus hernia include:

- Heartburn
- Dysphagia
- Regurgitation
- Odynophagia
- Shortness of breath
- Chronic cough
- Chest pain

# Differential Diagnosis

Conditions to consider in the differential diagnosis of hiatus hernia include:

- Gastroesophageal reflux disease (GORD): Heartburn, regurgitation, difficulty swallowing
- Gastritis: Abdominal pain, nausea, vomiting
- Peptic ulcer: Abdominal pain, bloating, feeling of fullness
- Gallstones: Severe abdominal pain, jaundice, fever

# Investigations

Hiatus hernias can be diagnosed using:

- **Barium swallows** (upper GI series), which is the most sensitive method
- **Endoscopy**
- **Oesophageal manometry**

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# Management

Management of hiatus hernia involves a combination of conservative, medical, and surgical strategies.

## Conservative management

Conservative management involves lifestyle changes such as:

- Weight loss
- Elevating the head of the bed
- Avoidance of large meals and eating 3-4 hours before bedtime
- Avoidance of alcohol and acidic foods
- Smoking cessation as nicotine relaxes the lower oesophageal sphincter. Other substances and medications that can relax the lower oesophageal sphincter include chocolate, peppermint, caffeine, fatty foods, and medications such as calcium-channel blockers, nitrates, and beta-blockers

## Medical management

Medical management involves the use of proton pump inhibitors (PPIs) for 4-8 weeks before assessing response.

## Surgical management

Surgical management includes Nissen's fundoplication in cases of medication-resistance or patient preference. This procedure involves closing the defect by tightening the crura and wrapping the gastric fundus around the lower oesophageal sphincter. Urgent surgery is required in the presence of haemorrhage, volvulus, ischaemia, necrosis or obstruction.
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A chest x-ray showing a hiatus hernia.
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Hiatus hernia management
Topic
23
Gastroenterology
Condition
319
Hiatus hernia
UkmlaTopic
11
Gastrointestinal including liver
Condition
320
Hiatus hernia
UkmlaTopic
12
General practice and primary healthcare
15704
In patients with a sliding hiatus hernia causing symptoms such as heartburn, belching and coughing during meals, initial management should include lifestyle modifications, weight loss, and acid suppressant therapy before considering surgical intervention.
Presentation
530
Swallowing problems
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3
Cancer
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Swallowing problems
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Ear, nose and throat
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532
Swallowing problems
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11
Gastrointestinal including liver
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533
Swallowing problems
UkmlaTopic
12
General practice and primary healthcare
Presentation
534
Swallowing problems
UkmlaTopic
17
Neurosciences
A 50-year-old woman has had heartburn, belching and coughing during meals for the last two months. She is overweight and drinks 16 units of alcohol a week. Imaging investigations demonstrate a sliding hiatus hernia.

What is the most appropriate management?
a