The management of hiatal hernia: an update on diagnosis and treatment

Abstract

Background and aim. Hiatal hernia (HH) occurs quite frequently in the general population and is characterized by a wide range of non-specific symptoms, most of them related to gastroesophageal reflux disease. Treatment can be challenging at times, depending on the existence of complications. The most recent guideline regarding the management of hiatal hernia was released by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in the year 2013. This review aims to present the most recent updates on the diagnosis and management of hiatal hernia for clinical practitioners.
 Methods. The PubMed database was screened for publications using the terms: “hiatal hernia”, “paraesophageal hernia”, “management”, “treatment”, “hiatal repair”. A literature review of contemporary and latest studies was completed. The studies that we looked into include prospective, randomized trials, systematic reviews, clinical reviews and original articles. The information was compiled in narrative review format.
 Results. This narrative review presents new data on the diagnosis and management of hiatal hernia. While the diagnostic pathway has remained virtually unchanged, new data have come to light regarding the surgical treatment of hiatal hernia. We present the imaging methods used for its diagnosis, as well as the medical and surgical treatment currently available.
 Conclusions. In the last five years, there has been vast research in the field of hiatal hernia management, especially regarding the surgical treatment. However, unanswered questions still remain and solid updates on the guidelines have yet to be formulated. To address this, more randomized studies need to be done on subsets of patients, stratified by age, gender, symptoms and comorbidities.

Minding the Gap: Clinical Manifestations of a Rare Type IV Hiatal Hernia

“…There are multiple diagnostic techniques that are of use in diagnosing hiatal hernias. Using some of these modalities can be challenging because of the irregularities seen in the anatomy of the GE junction during respiration, movement, and swallowing [6]. Barium swallow radiography provides important details of the upper gastrointestinal tract, including insight of disease pathology, in this case, the size of the herniated portion of the stomach as well as the position of the GE junction.…”

“…It is well documented that barium swallow is a useful tool in the diagnosis of hiatal hernias [7]. Esophagogastroduodenoscopy (EGD) is also used for real-time evaluation of the esophageal, stomach, and duodenal mucosa [6]. However, a disadvantage of EGD, especially in the case of the preceding patient, is the inability to appreciate large hiatal hernias [8].…”

Chest Pain: A Relatively Benign Symptom of Type IV Hiatal Hernia

“…Hiatal hernias can be classified into four distinct subtypes (types I-IV) based on the structures displaced through the esophageal opening of the diaphragm into the mediastinum. Type I hernias, also known as SHH, account for approximately 90% of the cases while the incidence of types II-IV varies between 5% and 10% [ 4 ] in patients. Type I hiatal hernias tend to be less severe in intensity with minimal complications; however, the complication rate is high for the latter types.…”

“…The American College of Gastroenterology (ACG) recommends a twice-daily therapy with PPIs for a period of eight weeks [ 13 ]. Prokinetic agents do not have a major role in the management of hiatal hernias [ 4 ]. Surgical intervention is reserved for large hernias, PEHs with recurring symptoms, and in patients presenting with clinical features of incarceration or strangulation of the abdominal contents [ 14 ].…”

“…Moreover, in patients who are candidates for bariatric surgery, laparoscopic sleeve gastrectomy can be performed simultaneously with the hernia repair and has additional advantages as proposed in the study conducted by Mahawar et al [ 17 ]. Laparoscopic fundoplication is currently the most frequently used procedure alongside surgical repair to control the symptoms of reflux [ 4 ]. Manometry helps to quantify the degree of reflux which should be taken into account before a planned fundoplication [ 15 , 16 ].…”