Paraesophageal and hiatal hernia: Clinical sciences

Paraesophageal and hiatal hernias are a condition where a part of the stomach or other abdominal organ moves upward through the diaphragmatic hiatus and into the chest cavity. This occurs when the phrenoesophageal membrane weakens and the diaphragmatic esophageal hiatus widens, allowing upward movement of intra-abdominal organs.

These hernias are categorized into 4 types depending on the organs displaced into the chest. A Type I is where the gastroesophageal junction, or GEJ for short, migrates above the diaphragm. This is also known as a sliding hernia because sometimes the GEJ can slide above and below the diaphragm.

Type II occurs when part of the gastric fundus has herniated through the hiatus and lies next to the esophagus. The GEJ is usually in its normal location below the diaphragm. Type III is a combination of Types I and II, where both the GEJ and a part of the stomach are above the hiatus. Finally, Type IV occurs when an intra-abdominal organ such as the colon, spleen, pancreas, or small intestine herniates through the hiatus.

Now, when assessing patients with a chief concern suggesting a paraesophageal or hiatal hernia, your first step is to perform an ABCDE assessment to determine if the patient is stable or unstable.

If the patient is unstable, begin acute management immediately to stabilize the airway, breathing, and circulation. This means you might need to intubate the patient to secure the airway, while obtaining IV access, beginning IV fluid resuscitation, and continuously monitor vital signs. Additionally, make the patient NPO and place a nasogastric tube for bowel decompression.

Once acute management has been initiated, your next step is to obtain a focused history and physical examination; order labs such as CBC, CMP, and lactate; and order imaging, including chest and abdominal X-rays.

On history, patients might report acute chest or abdominal pain and retching. On physical examination, you might find signs of shock such as altered mental status, tachycardia, and hypotension, as well as epigastric tenderness to palpation. You may also be unable to pass the NG tube due to resistance and obstruction, which is concerning for gastric volvulus, where the stomach rotates, causing a closed-loop obstruction.

Here’s a clinical pearl! Borchardt’s triad consists of inability to pass an NG tube, unproductive retching, and severe epigastric pain. These findings are highly suggestive of a gastric volvulus which needs to be released quickly to avoid progression to ischemia and perforation of the stomach!

Now, for labs, typically CBC reveals leukocytosis, CMP reveals electrolyte imbalances, and an elevated lactate level, indicating metabolic acidosis associated with low tissue perfusion. Chest and abdominal X-rays often show a gastric or bowel soft tissue shadow above the diaphragm. If these findings are present, you should suspect an incarcerated or strangulated paraesophageal or hiatal hernia with serious concern for ischemia, necrosis, or perforation, which are all surgical emergencies.

Next, consult the surgical team right away for an emergent operative repair. Now, if your patient is stable enough for a CT, obtain a CT of the chest and abdomen to confirm the diagnosis. The CT will show herniation of the stomach or abdominal organs into the chest with bowel wall thickening and edema consistent with a incarcerated or strangulated paraesophageal or hiatal hernia.

Continue IV fluid resuscitation, along with electrolyte replacement, broad-spectrum IV antibiotics, and possible vasopressor support; as well as bowel rest. These measures should start prior to the patient going to the operating room, but nothing should delay the surgical intervention!

Alright, now that unstable patients are taken care of, let's go back and talk about the stable ones. Your first step is to obtain a focused history and physical examination. Keep in mind that most patients with hiatal hernias do not experience any symptoms and are diagnosed incidentally during routine CT scans for other reasons.

However, if they’re experiencing symptoms, they typically report intermittent epigastric or retrosternal burning chest pain, which is often worse after eating and relieved with vomiting; as well as dysphagia, regurgitation, early satiety, and retching. Other symptoms include those associated with GERD, like water brash, or an excessive amount of sour-tasting saliva that worsens when lying down shortly after meals.