Hiatus hernia

Overview

Sliding vs rolling hiatus hernia

Feature	Sliding (Type I)	Rolling / para-oesophageal (Type II)
GOJ position	Migrates above diaphragm	Remains below diaphragm
Mechanism	LOS displaced into thorax - impaired anti-reflux barrier	Gastric fundus herniates alongside oesophagus; LOS preserved
Dominant symptoms	Heartburn, regurgitation (GORD)	Early satiety, chest pain; GORD less prominent
Main complication	Oesophagitis, Barrett's, stricture	Gastric volvulus, strangulation
Management	Lifestyle + PPIs; surgery if refractory	Elective surgical repair even if asymptomatic (high volvulus risk)

•Heartburn - burning retrosternal discomfort, worse after meals, lying flat, or bending forward

•Regurgitation - effortless return of acid/food, worse at night; risk of aspiration and chronic cough

•Dysphagia - suggests oesophagitis, stricture, or mechanical compression from large rolling hernia

•Iron deficiency anaemia - Cameron lesions (linear erosions at diaphragmatic hiatus in large hernias)

🚨

Rolling hernia acute emergency: severe chest pain + retching without vomiting + inability to pass NG tube = Borchardt's triad of gastric volvulus. Do not be falsely reassured by absence of GORD symptoms.

Investigations

🥇 First-line

•Upper GI endoscopy (OGD) - directly visualises hernia, GOJ position, and mucosal complications (oesophagitis, Barrett's, Cameron lesions); preferred with alarm symptoms or age >55

•Barium swallow - demonstrates hernia anatomy dynamically; useful when dysphagia is prominent or endoscopy inconclusive

•Incidental finding: CXR - air-fluid level or gas bubble behind cardiac shadow suggests large hernia

•Gold standard (GORD confirmation): 24-hour oesophageal pH monitoring - objectively confirms pathological acid exposure when endoscopy normal but symptoms persist

•Pre-operative: Oesophageal manometry - assesses LOS pressure and motility; required before fundoplication to exclude motility disorders

Management

•Lifestyle (always first): weight loss, avoid large meals, eat ≥3 hours before lying down, elevate head of bed, reduce alcohol and caffeine, stop smoking

🥇 First-line

•omeprazole 20 mg once daily (or lansoprazole 30 mg once daily) - PPI; use lowest effective dose with regular review

•Adjunct: alginate-antacid combinations (e.g. Gaviscon Advance) - raft formation reduces post-meal reflux; useful on-demand

🥈 Second-line

•H2-receptor antagonists (e.g. famotidine 20 mg twice daily) - if PPIs not tolerated; less potent

•Third-line / surgical: Laparoscopic Nissen fundoplication - 360° wrap of gastric fundus around distal oesophagus; indicated for refractory symptoms, patient preference, or large symptomatic para-oesophageal hernia; requires pre-operative manometry

💡

PPIs control symptoms but do not repair the anatomical defect. Long-term PPI risks include hypomagnesaemia, C. difficile infection, and increased fracture risk. Rolling hernias are often repaired electively even when asymptomatic - emergency repair carries significantly higher morbidity than elective repair.

Complications

•Barrett's oesophagus - metaplastic change (squamous → columnar) from chronic acid injury; pre-malignant, requires endoscopic surveillance

•Oesophageal stricture - fibrosis from repeated mucosal injury; managed with endoscopic dilatation

•Cameron lesions - chronic iron deficiency anaemia; often overlooked cause

•Gastric volvulus - twisting of herniated stomach in thorax; surgical emergency (Borchardt's triad)

•Oesophageal adenocarcinoma - long-term risk via Barrett's oesophagus