Key Facts

Hiatus hernias are extremely common, especially in the elderly. Sliding hernias are by far the most common type and contribute to GORD. Para-oesophageal hernias are less common but carry a risk of serious complications including gastric volvulus.

Epidemiology

Prevalence increases with age: ~10% at age 40, ~70% at age 70. Common in Western populations (associated with obesity). Many are asymptomatic and found incidentally on imaging or endoscopy. Sliding type accounts for ~80%. Para-oesophageal hernias are much less common (~5% of hiatus hernias).

Aetiology

• Weakening of the phrenico-oesophageal membrane and diaphragmatic crura with age
• Increased intra-abdominal pressure: obesity, pregnancy, chronic cough, heavy lifting, constipation
• Previous oesophageal/gastric surgery
• Connective tissue disorders (Ehlers-Danlos, Marfan)
• Shortened oesophagus (chronic GORD with fibrosis)

Pathophysiology

Sliding: the GOJ migrates upward through the hiatus into the thorax → disrupts the angle of His and LOS mechanism → predisposes to GORD. Para-oesophageal: the gastric fundus herniates alongside the oesophagus (GOJ stays in situ) → the herniated portion can undergo organoaxial rotation → volvulus → obstruction, ischaemia, perforation (surgical emergency). Large hiatus hernias can cause Cameron lesions (linear erosions at the hiatal level → iron deficiency anaemia).

Sliding Hiatus Hernia

• Often asymptomatic
• GORD symptoms: heartburn, acid regurgitation, dysphagia
• Oesophagitis, Barrett's oesophagus (long-term GORD)

Para-oesophageal Hernia

• Often asymptomatic or mildly symptomatic
• Postprandial fullness, early satiety
• Dysphagia (gastric compression of oesophagus)
• Chest pain (can mimic cardiac pain)
• Iron deficiency anaemia (Cameron lesions)

Complications

• Gastric volvulus: acute severe epigastric/chest pain, retching without ability to vomit (Borchardt's triad: severe epigastric pain, retching without vomiting, inability to pass NG tube)
• Incarceration/strangulation: surgical emergency

Red Flags

• Borchardt's triad (gastric volvulus — surgical emergency)
• Acute chest/abdominal pain in patient with known large hiatus hernia
• Unexplained iron deficiency anaemia (Cameron lesions)
• Progressive dysphagia (exclude malignancy)

Imaging

• CXR: may show retrocardiac soft tissue shadow or air-fluid level behind the heart (large hernia)
• Barium swallow: demonstrates hernia anatomy and type; shows GOJ position and any volvulus
• OGD: visualises hernia, assesses for oesophagitis, Barrett's, Cameron lesions; Hill classification of GOJ (I-IV)
• CT thorax/abdomen: for large/complicated hernias; defines anatomy for surgical planning

Bloods

• FBC: iron deficiency anaemia (Cameron lesions, chronic blood loss)
• Iron studies: if anaemia present

Special Tests

• Oesophageal manometry: before fundoplication surgery (exclude oesophageal dysmotility)
• 24-hour pH/impedance study: quantify acid reflux if diagnosis uncertain or pre-operatively

Non-pharmacological (Sliding Hernia)

• Lifestyle modifications: weight loss, raise head of bed, avoid late meals, reduce alcohol/caffeine, smoking cessation, avoid tight clothing
• Dietary: small frequent meals, avoid trigger foods (fatty, spicy, acidic)

Pharmacological (Sliding Hernia)

• PPI: first-line — omeprazole 20-40 mg OD or lansoprazole 15-30 mg OD; step down to lowest effective dose
• H2RA: ranitidine alternative (note: ranitidine withdrawn in 2020 due to NDMA contamination; use famotidine 20 mg BD)
• Alginate antacids: Gaviscon Advance 10-20 mL after meals and at bedtime

Surgical

• Sliding hernia: laparoscopic Nissen fundoplication (360° wrap) or Toupet (270° posterior wrap) if refractory GORD despite maximal PPI, large hernia, or patient preference to avoid lifelong PPI
• Para-oesophageal hernia: elective laparoscopic repair recommended for symptomatic hernias (hernia reduction, crural repair ± mesh, ± fundoplication); lower operative risk than emergency surgery
• Emergency surgery: for acute gastric volvulus, strangulation, or perforation — open or laparoscopic reduction + repair + assess gastric viability
• Asymptomatic large para-oesophageal hernia: controversial — some advocate elective repair in fit patients due to volvulus risk; watchful waiting acceptable if asymptomatic and significant surgical risk

Referral Criteria

• Upper GI surgery: symptomatic para-oesophageal hernia (elective repair)
• Emergency surgery: gastric volvulus, strangulation
• Gastroenterology: refractory GORD, Barrett's surveillance, iron deficiency anaemia
• OGD: dysphagia, alarm symptoms, pre-operative assessment

Sliding hiatus hernia: excellent prognosis; well-controlled with PPI in most cases. Fundoplication success rate >85% for symptom relief. Para-oesophageal hernia: elective repair has low mortality (<1%); emergency surgery for volvulus has mortality ~5-15%. Recurrence after surgical repair: ~5-15% (higher for large hernias). Cameron lesion anaemia resolves with PPI ± iron therapy + hernia repair.

Types of Hiatus Hernia

Borchardt's Triad (Gastric Volvulus)