Ref: Hiatus Hernia. (n.d.). Retrieved July 6, 2015.

WHAT IS IT?
A structural abnormality in which a portion of the stomach protrudes upwards through
the diaphragm.
TYPES OF HIATUS HERNIA
Sliding hiatus hernia (the most common) is where an unusually short oesophagus, that
ends above the diaphragm, pulls a part of the stomach upwards into the thorax. The
sliding movement is due to the normal shortening of the oesophagus by muscular
contracture during swallowing (Waugh and Grant, 2002).
Rolling hiatus hernia (or para-oesophageal hernia) is where an abnormally large
opening in the diaphragm allows a pouch of stomach to roll upwards into the thorax
beside the oesophagus (Waugh and Grant, 2002). This condition can present as a
surgical emergency.
The long-term effects can be oesophagitis or oesophageal stricture resulting in
dysphagia.
RISK FACTORS
- Pregnancy
- Smoking.
- Congenital factors.
- Eating large meals, particularly at night.
- Obesity.
- Increasing age: hiatus hernia occurs most frequently from middle age onwards
(Howie et al, 2001).
- Bending and lying postures.
- Wearing tight clothing around the waist.

- Hiatus hernia is four times more common in women than in men (Howie et al,
2001).
SIGNS AND SYMPTOMS
Sliding
- Heartburn - a painful burning sensation in the oesophagus, just below the sternum.
This is due to gastro-oesophageal reflux, a back-flow of gastric acid into the
oesophagus. It often worsens on bending or lying down.
- Dysphagia due to inflammation, muscle spasm or ulceration as a result of reflux
oesophagitis.
- Recurrent pneumonitis due to aspiration.
- Complications can include persistent reflux, inhalation pneumonia and chronic blood
loss anaemia (McLatchie and Leaper, 2002).
Rolling
- Dysphagia; feeling of fullness, distension and chest discomfort after meals.
- Cardiac arrythmias.
- Hiccups.
- Complications can include gangrene and gastric ulceration (McLatchie and Leaper,
2002).
INVESTIGATIONS
- Medical history.
- Barium swallow and meal.
- Oesophagogastroscopy.
- X-ray (the condition is sometimes picked up on a routine chest X-ray).
TREATMENT

Sliding: treatment should aim to alleviate the discomfort caused by reflux. Antacids
(such as Gaviscon) can provide symptom relief as they form a temporary layer over
stomach contents. Protein pump inhibitor (PPI) medication can help to inhibit acid
secretion completely.
Rolling: surgical treatment may be required in view of the high risk of complications.
NURSING IMPLICATIONS
Health advice concerning: smoking cessation; weight loss; small frequent meals at
regular intervals; posture; bending and lifting in the workplace; sleeping with an extra
pillow.
Reflux can be very distressing and can be mistaken for angina.
Ref: Hiatal Hernia Treatment & Management. (n.d.). Retrieved July 6, 2015.

Surgical Care
The goal of surgery is to remove the hernia sac and close the abnormally wide
esophageal hiatus.
Surgery is necessary only in the minority of patients with complications of GERD
despite aggressive treatment with proton pump inhibitors (PPIs). Because only a
minority of patients with hiatal hernia have any problems, this represents a very small
proportion of patients with sliding hiatal hernia; most patients with problems are
managed medically.
By far, the majority of patients who would have undergone surgery in the past are
managed successfully today with PPIs. However, young patients with severe or
recurrent complications of GERD, such as strictures, ulcers, and bleeding, who cannot
afford lifelong PPI treatment or would prefer to avoid taking medications long term,
may be surgical candidates. Another group of patients who are surgical candidates are
those with pulmonary complications, in particular, asthma, recurrent aspiration
pneumonia, chronic cough, or hoarseness linked to reflux disease.
Most patients with a paraesophageal hernia remain asymptomatic. In this type of
hernia, symptoms from acid reflux usually do not occur. Instead, the most common
symptom is epigastric or substernal pain. Some patients complain of substernal
fullness, nausea, and dysphagia. A significant proportion of patients with this type of
hernia develop incarceration of the hernia and possible gastric volvulus, which can

lead to perforation. If perforation occurs, the mortality rate is high. Because of this,
many surgeons advise elective repair when the diagnosis is made.
A patient with a large hiatal hernia may experience vague intermittent chest
discomfort or pain. The paraesophageal hernia may strangulate and frequently is
operated on prophylactically to prevent this complication. Paraesophageal hernias
may present in infants or adults as a potentially life-threatening complication of
strangulation, and prompt surgical repair is key. When found in asymptomatic
individuals, laparoscopic repair is often undertaken, with large defects in the
diaphragm being closed with mesh.[8, 9, 10, 11]
Three major types of surgical procedures correct gastroesophageal reflux and repair
the hernia in the process. They can be performed by open laparotomy or with
laparoscopic approaches, which currently are being employed more frequently. These
procedures offer relief of symptoms in 80-90% of patients.
In most cases, the procedure of choice is the one with which the surgeon is most
familiar. These procedures carry low mortality and morbidity rates, lower than 1520%. DeMeester et al found the Nissen procedure superior to the Belsey and Hill
repairs with regard to symptom relief and prevention of reflux postoperatively (as
judged by pH monitoring). Good long-term results have been reported for antireflux
surgery, with adequate control of reflux in the range of 80% at 10 years.
See the video below for a discussion of surgical options for paraesophageal hernia
repair.
Inderpal S. Sarkaria, MD, discusses the options for paraesophageal hernia repair.
Courtesy of Memorial Sloan-Kettering Cancer Center.
Nissen fundoplication
The Nissen fundoplication performed laparoscopically has gained popularity because
of its lower morbidity and shorter hospital stay compared to the open procedure
performed previously. Although a relatively high incidence of postoperative
complications, such as dysphagia and gas bloating, are reported, DeMeester and
Peters[12] have shown that placing a larger bougie in the esophagus during this
procedure, along with a shorter wrap and more complete mobilization of the stomach,
have markedly reduced postoperative complications. [13, 14]
This procedure involves a 360 fundic wrap around the gastroesophageal junction.
The diaphragmatic hiatus also is repaired.

A transthoracic approach may be used in patients who have had a previous Nissen
wrap or those who have an irreducible hernia.
In a study involving 26 patients who underwent Nissen fundoplication, the use of
permanent mesh following fundoplication resulted in symptom improvement in 23
patients (88.5%), with hernia recurrence reported by the remaining three patients
(11.5%). No mesh erosions occurred during the mean 65-month follow-up period. [15]
The Toupet procedure is a variant of the Nissen wrap and involves a 180 wrap in an
attempt to lessen the likelihood of postoperative dysphagia.
Belsey fundoplication
This operation involves a 270 wrap in an attempt to reduce the incidence of gas
bloating and postoperative dysphagia. It also is preferred when minimal esophageal
dysmotility is suspected. To complete this operation, the left and right crura of the
diaphragm are approximated.
Hill repair
In this procedure, the cardia of the stomach is anchored to the posterior abdominal
areas, such as the medial arcuate ligament. This also has the effect of augmenting the
angle of His and thus strengthening the antireflux mechanism.
Some surgeons then tack the stomach down in the abdomen to prevent it from
migrating upwards again, or, they perform a temporary gastrostomy to help
decompress the stomach and anchor it in place in the abdominal cavity.
Ref: Nursing Interventions for Hiatal Hernia. (n.d.). Retrieved July 6, 2015
Nursing Interventions: Hiatal Hernia
1. Prepare the patient for diagnostic tests, as needed.
2. Administer prescribed antacids and other medications
3. To reduce intra-abdominal pressure and prevent aspiration, have the
patient sleep in a reverse Trendelenburg position with the head of the
bed elevated.
4. Assess the patients response to treatment.
5. Observe for complications, especially significant bleeding, pulmonary
aspiration, or incarceration or streangulation of the herniated stomach
portion.

6. After endoscopy, watch for signs of perforation such as falling blood

pressure, rapid pulse, shock, and sudden pain caused by endoscope.
7. To enhance compliance, teach the patient about the disorder. Explain
significant symptoms, diagnostic tests, and prescribed treatments.
8. Review prescribed medications, explaining their desired actions and
possible adverse effects.
9. Teach the patient dietary changes to reduce reflux.
10.
Encourage the patient to delay lying down for 2 hours after
eating.