eMedicine Specialties > Gastroenterology > Esophagus

Hiatal Hernia: Treatment & Medication

Author: Waqar A Qureshi, MD, Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Aug 24, 2009

Treatment

Medical Care

When hiatal hernias are symptomatic, acid reflux usually produces the symptoms. If the hernia itself is causing chest discomfort or other symptoms, surgery may be necessary.

  • When symptoms are due to GERD, the goals of treatment include prevention of reflux of gastric contents, improved esophageal clearance, and reduction in acid production. This is achieved in the majority of patients by a combination of the following:
    • Modifying lifestyle factors
    • Neutralizing acid or inhibiting acid production
    • Enhancing esophageal and gastric motility
  • The treatment of GERD is beyond the scope of this article and is discussed in Gastroesophageal Reflux Disease.
  • Large hiatal hernias may cause iron deficiency anemia regardless of whether Cameron ulcers are present. This anemia responds well to PPI therapy with surgery offering no clear advantage over medical therapy.

Surgical Care

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.5,6

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.

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.

  • 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 Peters7 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.8,9
    • 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.
    • 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 (Mark IV) 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.
  • The antireflux procedures discussed above 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 15-20%. 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.
  • 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.
    • The goal of surgery is to remove the hernia sac and close the abnormally wide esophageal hiatus.
    • 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.

Diet

  • An appropriate diet maintains an ideal body mass index. Obesity predisposes to reflux disease.
  • Burkitt et al suggest that the Western, fiber-depleted diet leads to a state of chronic constipation and straining during bowel movement, which would explain the higher incidence of this condition in Western countries.1

Medication

Symptomatic acid reflux can be treated medically, either by neutralizing acid with antacids or blocking acid secretion with H2-receptor blocking drugs or the more potent PPIs. The treatment of GERD is discussed in Gastroesophageal Reflux Disease. Hiatal hernias, per se, only require attention if they are causing symptoms because of their size or if the patient is at risk of strangulation, in which case surgery may be indicated.

More on Hiatal Hernia

Overview: Hiatal Hernia
Differential Diagnoses & Workup: Hiatal Hernia
Treatment & Medication: Hiatal Hernia
Follow-up: Hiatal Hernia
Multimedia: Hiatal Hernia
References
Further Reading
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References

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  2. Larusson HJ, Zingg U, Hahnloser D, Delport K, Seifert B, Oertli D. Predictive factors for morbidity and mortality in patients undergoing laparoscopic paraesophageal hernia repair: age, ASA score and operation type influence morbidity. World J Surg. May 2009;33(5):980-5. [Medline].

  3. Sihvo EI, Salo JA, Rasanen JV, Rantanen TK. Fatal complications of adult paraesophageal hernia: a population-based study. J Thorac Cardiovasc Surg. Feb 2009;137(2):419-24. [Medline].

  4. Salvador R, Dubecz A, Polomsky M, Gellerson O, Jones CE, Raymond DP, et al. A new era in esophageal diagnostics: the image-based paradigm of high-resolution manometry. J Am Coll Surg. Jun 2009;208(6):1035-44. [Medline].

  5. Hazebroek EJ, Leibman S, Smith GS. Erosion of a composite PTFE/ePTFE mesh after hiatal hernia repair. Surg Laparosc Endosc Percutan Tech. Apr 2009;19(2):175-7. [Medline].

  6. Soricelli E, Basso N, Genco A, Cipriano M. Long-term results of hiatal hernia mesh repair and antireflux laparoscopic surgery. Surg Endosc. Apr 3 2009;[Medline].

  7. DeMeester TR, Peters JH. Surgical treatment of gastroesophageal reflux disease. In: DO Castell, ed. The Esophagus. Boston, Mass:. Little, Brown and Company;1995:577-617.

  8. Frantzides CT, Madan AK, Carlson MA, Zeni TM, Zografakis JG, Moore RM, et al. Laparoscopic revision of failed fundoplication and hiatal herniorraphy. J Laparoendosc Adv Surg Tech A. Apr 2009;19(2):135-9. [Medline].

  9. Cai W, Watson DI, Lally CJ, Devitt PG, Game PA, Jamieson GG. Ten-year clinical outcome of a prospective randomized clinical trial of laparoscopic Nissen versus anterior 180( degrees ) partial fundoplication. Br J Surg. Dec 2008;95(12):1501-5. [Medline].

  10. Allen CJ, Newhouse MT. Gastroesophageal reflux and chronic respiratory disease. Am Rev Respir Dis. Apr 1984;129(4):645-7. [Medline].

  11. Berstad A, Weberg R, Froyshov Larsen I et al. Relationship of hiatus hernia to reflux oesophagitis. A prospective study of coincidence, using endoscopy. Scand J Gastroenterol. Jan 1986;21(1):55-8. [Medline].

  12. Drewitz DJ, Sampliner RE, Garewal HS. The incidence of adenocarcinoma in Barrett''s esophagus: a prospective study of 170 patients followed 4.8 years. Am J Gastroenterol. Feb 1997;92(2):212-5. [Medline].

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  21. Panzuto F, Di Giulio E, Capurso G. Large hiatal hernia in patients with iron deficiency anaemia: a prospective study on prevalence and treatment. Aliment Pharmacol Ther. Mar 15 2004;19(6):663-70. [Medline].

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  25. Pridie RB. Incidence and coincidence of hiatus hernia. Gut. Apr 1966;7(2):188-9. [Medline].

  26. Rolla G, Colagrande P, Magnano M. Extrathoracic airway dysfunction in cough associated with gastroesophageal reflux. J Allergy Clin Immunol. Aug 1998;102(2):204-9. [Medline].

  27. Tardif C, Nouvet G, Denis P. Surgical treatment of gastroesophageal reflux in ten patients with severe asthma. Respiration. 1989;56(1-2):110-5. [Medline].

  28. Toohill RJ, Kuhn JC. Role of refluxed acid in pathogenesis of laryngeal disorders. Am J Med. Nov 24 1997;103(5A):100S-106S. [Medline].

  29. Waring JP, Lacayo L, Hunter J et al. Chronic cough and hoarseness in patients with severe gastroesophageal reflux disease. Diagnosis and response to therapy. Dig Dis Sci. May 1995;40(5):1093-7. [Medline].

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Further Reading

Related eMedicine topics

Clinical Trials

Clinical Guideline

  • Hernia. Work Loss Data Institute - Public For Profit Organization. 2003 (revised 2008 Mar 10). 43 pages. NGC:006559

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Keywords

hiatal hernia, hernias, paraesophageal hernias, paraesophageal hiatal hernia, esophageal hernia, hernia surgery, gastroesophageal reflux disease, GERD, gastric volvulus, hiatus hernia, Schatzki ring, phrenoesophageal ligament, esophagitis, Cameron ulcers, sliding hiatal hernia, regurgitation

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Contributor Information and Disclosures

Author

Waqar A Qureshi, MD, Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center
Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Vivek V Gumaste, MD, Associate Professor of Medicine, Mt Sinai School of Medicine; Adjunct Clinical Assistant, Mt Sinai Hospital; Director, Division of Gastroenterology, City Hospital Center
Vivek V Gumaste, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Oscar S Brann, MD, FACP, Associate Clinical Professor, Department of Medicine, University of California at San Diego; Consulting Staff, Mecklenburg Medical Group
Oscar S Brann, MD, FACP is a member of the following medical societies: American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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