Hiatal Hernia: BY MR, Vinay Kumar

HIATAL HERNIA
BY
Mr, Vinay Kumar
 Hiatal hernia is the protrusion of the stomach upward into the mediastinal cavity through
the esophageal hiatus of the diaphragm.
Normally, a portion of the esophagus and all the stomach are situated in the abdominal
cavity.
Normal Hiatal Hernia

PATHOPHYSIOLOG
Y
 Size of hiatus not fixed, narrows with increase in
intra- abdominal pressure
 Tear of Phrenoesophageal ligament :
is a fibrous layer of connective tissue and maintains the

LES within the abdominal cavity
 A hiatal hernia compromises reflux barrier
 Reduced LES pressure
 Reduced esophageal acid clearance
 Transient LES relaxation episodes particularly at night time

Types of Hiatal Hernia
1. Sliding hiatal hernia:
 Herniation of both the stomach and the
gastroesophageal(GE) junction into the thorax.
 90% of esophageal hernias
2. Paraesophageal hiatal hernia:
 Herniation of all or part of the stomach through the
esophageal hiatus into the thorax with an undisplaced
GE junction
 Least common esophageal hernia (<10%)
Risk factors for Hiatal Hernia
o Age
o Heavy lifting or bending over.
o Frequent or hard coughing.
o Hard sneezing.
o Pregnancy and delivery.
o Vomiting.
o Constipation.
o Obesity.
Clinical features of Hiatal Hernia
The patient with sliding hernia may have,

• Heart burn
• Regurgitation and
• Dysphagia but at least 50% are Asymptomatic.
The patient with paraoesophageal hernia usually

feels a sense of fullness after eating or may be
asymptomatic.
Complications of Hiatal Hernia
• Dysphagia.
• Esophagitis.
• Gastroesophageal reflex.
• Infection or bleeding.
• Damage of the internal organ e.g. heart, lungs etc.
• Heart burn.
Investigations Hiatal Hernia
 Chest X-ray
 Barium swallow
 Endoscopy
 Esophageal manometry (to measure the pressure of LES)
 24-48h esophageal pH monitoring to quantify reflux
 Gastroscopy with biopsy to rule out cancer and esophagitis

Endoscopic
view:
Barium swallow demonstrates hiatal
hernia:
Treatment of Hiatal Hernia
 LIFESTYLE MODIFICATION
 Stop smoking,
 weight loss,
 elevate head of bed,
 no meals <3h prior to sleeping,
 smaller and more frequent meals,
 avoid too much alcohol, coffee, mint and fat.

MEDICAL
MANAGEMENT
Antacids The antacids act by neutralizing the acid in the stomach and
by inhibiting pepsin such as
H2 receptor antagonists- it reduce the amount of acid secretion in

stomach. e.g. Cimetidine
Proton pump inhibitors- it also reduces the acid secretion in stomach

e.g. Omeprazole
Prokinetic agents- it promote intestinal motility and are used for severe
constipation-predominant e.g. Metoclopramide
Surgical management
FundoplicationA laparoscopic procedure in which

the fundus of the stomach is wrapped around lower
end of esophagus.
Complications
• Dysphagia.
• Esophagitis.
• Gastroesophageal reflex.
• Infection or bleeding.
• Damage of the internal organ e.g. heart,
lungs etc.
• Heart burn.
Nursing process
Assessment Nursing diagnosis Goal Interventions Outcome
Bulging at hernia Risk of ineffective Complications will Watch for and There is no signs
site tissue perfusion be avoided next 24 immediately of complications
related to hernia hours report signs of within 24 hours
and the possibility incarceration and
of obstruction and strangulation
strangulation
Nursing process
Patient is Acute pain relate The patient will - Watch for and Pain was relieved
complaining of to swelling and express feelings immediately from 5 to 2 on
pan 5 on pressure of comfort. report signs of score
score incarceration and
strangulation.
- Administer I.V.
fluids and
analgesics for
pain as ordered.
- Place the patient
in
Trendelenburg's
position to
reduce pressure
on the hernia site
Nursing process
patient said that Risk of aspiration Client will be able - Instruct to take Patient has no
he often have oral related to reflux of to state the steps small frequent episodes of oral
regurgitation after gastric content in preventing meals regurgitation after
meals aspiration after 2 - Encourage not 2 hours of
hours of nursing to take meal interventions
interventions 2 hours
before bed
time
Nursing process
Patient has Fear and anxiety Pt to be free from - explain the Pt is relieved of
repeated doubts related to anxiety with 2 procedure to fear and anxiety as
regarding surgery hospitalization hours of the patient in he state it.
interventions simple terms
- introduce the
patient to
similar patients
who had
undergone the
surgery
Health education
• 1.) Educate patient to assess for any signs and symptoms of infection
such as redness, severe itchiness and condition at the surgical site.
• 2.) Advise patient come for follow-up to monitor patient

progress/condition.
• 3.) Educate patient to avoid wearing tight clothing to minimize

abdominal pressure
4.) Encourage patient avoid lifting heavy object or doing heavy
exercise at least 6 weeks
5.) Use proper lifting technique
6.) Lose weight
7.) Exercise regularly
8.) Advice patient to eat a vitamin-rich diet such as vitamin C and
protein to promote wound healing
9.) Encourage patient to take high fibers food to prevent constipation
References
 Renee C. Minjarez, M.D. and Blair A. Jobe, M.D. (2006).
"[Surgical therapy for gastroesophageal reflux disease.]". GI
Motility online
 http://emedicine.medscape.com/article/178393-overview.
Retrieved on 22nd February, 2016
 https://en.wikipedia.org/wiki/Esophageal_hiatus. Retrieved on
22nd February, 2016
 Hall, J. and Premji, A (2015). The Toronto notes 2015:
Comprehensive medical reference and review for the Medical
Council of Canada Qualifying Exam Part 1 and the United
States Medical Licensing Exam Step 2. Toronto: Toronto Notes
for Medical Students, Inc.

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HIATAL HERNIA

Normal Hiatal Hernia

is a fibrous layer of connective tissue and maintains the

 Reduced LES pressure

 Reduced esophageal acid clearance

 Transient LES relaxation episodes particularly at night time

The patient with sliding hernia may have,

The patient with paraoesophageal hernia usually

 Esophageal manometry (to measure the pressure of LES)

 24-48h esophageal pH monitoring to quantify reflux

 Gastroscopy with biopsy to rule out cancer and esophagitis

 elevate head of bed,

 no meals <3h prior to sleeping,

 smaller and more frequent meals,

 avoid too much alcohol, coffee, mint and fat.

H2 receptor antagonists- it reduce the amount of acid secretion in

Proton pump inhibitors- it also reduces the acid secretion in stomach

FundoplicationA laparoscopic procedure in which

• 2.) Advise patient come for follow-up to monitor patient

• 3.) Educate patient to avoid wearing tight clothing to minimize

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