HIATAL HERNIA. Distal esophagus- held in position by the phrenoesophageal ligament Occurs most commonly in women Most hiatal hernias are asymptomatic.

HIATAL HERNIA

HIATAL HERNIADistal esophagus- held in position by the

phrenoesophageal ligamentOccurs most commonly in womenMost hiatal hernias are asymptomatic5-10% of pts. will develop GERDThere is strong association with obesitySaint’s triad= gall stones+colonic

diverticular disease+hiatal hernia

HIATAL HERNIAType I or sliding HH: ph.-esoph. lig.intact but

lax- distal esoph. and cardia herniate through the hiatus.

Type II or paraesophageal HH- focal defect of the ph.-esoph. lig.- greater curvature herniates upward alongside the esoph.

Type III- a combination of type I and II

Sliding HH

HIATAL HERNIASYMPTOMSType I- sy. of associated GERDType II, III- postprandial pain,

- bloating,- breathlessness with meals,- mild dysphagia

The herniated gastric pouch is susceptible to volvulus, obstruction, infarction, ischemic ulcers, occult bleeding, perforation, gangrene.

HIATAL HERNIADIAGNOSIS AND EVALUATION

CXR- air/fluid level in post. M. on lat.view

Barium swallow- the dg. study of choice

Esophagoscopy- for GERD and esophagitis

Manometry and pH testing for refux sy.

Hiatus hernia seen from below with the endoscope in an inverted position inside the stomach

HIATAL HERNIAMANAGEMENT

Asymptomatic HH- no treatmentHH+GERD- medical treatmentIndications for surgery:

Symptomatic HH (chest pain, dysphagia)HH+ severe esophagitisHH type II, IIIOprative objectives: - reduction of hernia

- closure of the hiatal defect

- antireflux procedure