Hiatus Hernia and Paraoesophageal Hernia
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Direct answer
A hiatus hernia is protrusion of abdominal contents through the oesophageal hiatus of the diaphragm. Sliding hernias, which make up most cases, move the gastro-oesophageal junction upward and mainly cause reflux. Paraoesophageal (rolling) hernias keep the junction in place while the fundus herniates alongside the oesophagus, carrying a risk of obstruction, volvulus and strangulation that usually prompts elective repair.
What you must remember
- Sliding hernia: the gastro-oesophageal junction and cardia slide above the diaphragm, forming the commonest type and the usual cause of reflux symptoms.
- Rolling hernia: the junction stays below the hiatus while the gastric fundus rolls up beside the oesophagus, which is the paraoesophageal form.
- Classification: type I is sliding, type II is pure paraoesophageal, type III is mixed, and type IV adds other viscera such as colon or spleen.
- Borchardt triad: severe epigastric pain, retching without vomiting, and failure to pass a nasogastric tube into the stomach, classically seen in acute gastric volvulus.
- Cameron lesions: linear erosions on the mucosal folds at the hernia neck, a recognised cause of chronic iron deficiency anaemia.
- Investigation: a barium swallow shows the herniated stomach, a chest radiograph may show a retrocardiac air-fluid level, and endoscopy assesses oesophagitis and Barrett oesophagus.
- Surgical indication: symptomatic paraoesophageal hernias, especially with anaemia, dysphagia or volvulus, warrant elective repair because strangulation can be catastrophic.
- Acute volvulus: an emergency needing urgent decompression and surgery, with gastropexy added to reduce recurrence.
A pathway from symptoms to definitive treatment
Symptoms separate the two main types, and the presence of a strangulation picture decides how urgent treatment becomes. Most patients with reflux need medical care only, while a rolling hernia with obstructive symptoms usually needs surgery.
- Clarify the symptoms: Heartburn and regurgitation point towards a sliding hernia, while postprandial fullness, dysphagia or iron deficiency suggest a paraoesophageal type. Retching with an inability to pass a tube is an emergency.
- Confirm the anatomy: A barium swallow shows the herniated stomach and the level of the junction. Upper endoscopy then assesses oesophagitis, Barrett oesophagus and any ulceration.
- Treat reflux medically: A sliding hernia with reflux responds to weight reduction, head-of-bed elevation and proton pump inhibitors. The hernia itself is not an indication for surgery.
- Plan elective repair: A symptomatic paraoesophageal hernia is repaired laparoscopically by closing the hiatus, often with an anti-reflux wrap.
- Treat acute volvulus urgently: Suspect it with the Borchardt triad, decompress the stomach and operate promptly, because the gastric wall can become ischaemic.
Where the exam tries to catch you
Most lost marks come from treating an emergency as routine, or a routine problem as surgical.
- Trap: treating Borchardt triad as simple reflux with a proton pump inhibitor Correct: the triad signals acute gastric volvulus, which needs nasogastric decompression attempts, imaging and urgent surgery.
- Trap: attributing iron deficiency anaemia in an older woman with a large hernia to menstrual loss alone Correct: Cameron lesions can cause occult bleeding, so unexplained anaemia with a hernia warrants endoscopy.
- Trap: assuming a normal plain chest radiograph excludes a paraoesophageal hernia Correct: a plain film can miss it, and a barium swallow or CT defines the anatomy.
Frequently asked questions
Which type of hiatus hernia causes most reflux symptoms?
Sliding hiatus hernias cause most reflux symptoms, because the gastro-oesophageal junction sits above the diaphragm and loses its natural barrier against acid. Paraoesophageal hernias cause mainly obstructive, anaemic and postprandial symptoms rather than typical heartburn.
What is Borchardt triad and which condition does it describe?
Borchardt triad is severe epigastric pain, unproductive retching, and failure to pass a nasogastric tube into the stomach. It describes acute gastric volvulus, a surgical emergency that needs prompt decompression and operation.
Why are Cameron lesions important in hiatus hernia?
Cameron lesions are linear erosions on the mucosal folds at the hernia neck, where the stomach is squeezed by the hiatus. They can cause chronic occult bleeding and iron deficiency anaemia, so unexplained anaemia with a large hernia warrants endoscopy.
When is surgery indicated for a paraoesophageal hernia?
Symptomatic paraoesophageal hernias, especially those with dysphagia, anaemia or volvulus, warrant elective repair. Asymptomatic ones are often observed, while sliding hernias with reflux are managed medically rather than operated on.
Which investigation best defines the anatomy of a hiatus hernia?
A barium swallow defines the anatomy by showing the herniated stomach and the position of the junction relative to the diaphragm. Upper GI endoscopy complements it by detecting oesophagitis, Barrett oesophagus and Cameron lesions.