Paraesophageal and hiatal hernia: Clinical sciences

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Introduction0:00–1:29

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.

Unstable Patient1:29–4:49

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.

Stable Patient4:49–6:35

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.
Patients may also have respiratory symptoms such as shortness of breath, chronic cough, or recurrent aspiration. There may also be risk factors, such as obesity, smoking, and advanced age.
Chest and abdominal examination findings are typically normal. Based on these findings, you should suspect paraesophageal or hiatal hernia.
Next, to confirm your diagnosis, start with a chest X-ray, and obtain an esophagogastroduodenoscopy, or EGD for short. This is usually enough to confirm the diagnosis.
If it’s still unclear you can perform an upper GI contrast study. A CT of the chest and abdomen can also be ordered if there’s concern for a Type IV hernia or some other cause of the patient’s symptoms.
Now, let's talk about what you might see on imaging. On chest X-ray, you’ll often see a retrocardiac soft tissue opacity, while on CT you can expect to see the GEJ and gastric cardia within the chest, with the fundus of the stomach below the diaphragm.

Type I: Sliding hiatal hernia6:35–8:50

The upper GI contrast study will also likely reveal the GEJ and gastric cardia sliding into the chest, while the EGD will show the Z-line, indicative of the GEJ, located above the diaphragmatic hiatus.
These radiographic and endoscopic findings are diagnostic of Type I sliding hiatal hernia. Treatment for this type of hernia consists mostly of medical management with lifestyle modifications, antacids, and acid suppression medications like PPIs and H2-receptor antagonists.
However, if their reflux symptoms don’t resolve, or if they experience severe side effects from their medications, some patients might be a good candidate for a surgical repair like a fundoplication or a hiatoplasty, so consider referring them for a surgical consultation.
Here's a clinical pearl! In general, the surgical treatment for a hiatal hernia involves reducing the migrated stomach and possibly excising the hernia sac.
The hiatal defect is then closed with or without mesh. An anti-reflux wrap may also be performed.
There are three different types of wraps, all with varying degrees of wrapping the stomach around the esophagus depending on the type and severity of the hernia.
To determine which type of wrap is needed, esophageal manometry testing is used to assess the function of the esophagus.
So, if the patient has a poorly functioning esophagus they would not be a candidate for a 360-degree Nissen wrap, but instead would be considered for a Toupet, which is a posterior 270-degree wrap; or a Dor, which is an anterior 180 to 200-degree wrap.
Alright, let's move on to another set of findings you might see on imaging. Similar to a Type I hernia, you’ll often see a retrocardiac soft tissue opacity on chest X-ray, but this time there could be air-fluid levels indicating that a part of the stomach could be in the chest.

Type II: Paraesophageal hernia8:50–9:59

On CT, the GEJ typically remains in its anatomical position below the diaphragm, but there’s a partial herniation of the gastric fundus into the chest.
Likewise, the UGI contrast study will show partial herniation of the gastric fundus into the chest, and the EGD will show the Z-line below the diaphragmatic hiatus.
All of these findings confirm Type II paraesophageal hernia. For this type of hernia, the treatment is observation and medical management of GERD.
In some cases, if the patient continues to be symptomatic, they should be considered for an elective surgical management with hiatal herniorrhaphy with or without fundoplication.
This is often performed via a minimally invasive approach from the abdomen. Okay, let’s go back and discuss another set of imaging findings.

Type III: Mixed paraesophageal hernia9:59–10:52

The chest X-ray will often show a retrocardiac soft tissue opacity with or without air-fluid levels. On CT, you’ll see both the GEJ and gastric fundus herniated through the esophageal hiatus.
Similarly, the upper GI series shows both GEJ and the gastric fundus within the chest, and EGD reveals the Z-line above the diaphragm.
These findings are all characteristics of a Type III or mixed paraesophageal hernia. The treatment options for Type III hernia are similar to Type II, which includes observation, medical management of GERD, and elective surgical repair.
Alright, let’s talk about our last set of imaging. On chest X-ray, you’ll see a retrocardiac shadow of different abdominal organ structures like the small bowel, colon, spleen, or omentum.

Type IV: Complex paraesophageal hernia10:52–12:06

The CT scan typically confirms X-ray findings by providing better visualization of the abdominal organ that has herniated into the chest.
The upper GI contrast study often shows the GEJ below the diaphragm, but might also show an abdominal organ within the chest cavity.
Additionally, you can expect the EGD to show the Z-line is below the diaphragmatic hiatus. These findings indicate a Type IV or a complex paraesophageal hernia.
Treatment options are similar to Type II and III, which include observation, medical management of GERD, and elective hiatal hernia repair with fundoplication; however, these patients are more likely to be referred for surgery secondary to the size of the hernia and its contents.
Also, these surgeries are more complex and often require an approach through the chest via a thoracotomy and a diaphragmatic reconstruction.
Alright, as a quick recap… Patients with a paraesophageal or hiatal hernia may present as either stable or unstable. If a patient is unstable, and you suspect an incarcerated or strangulated hernia, consult the surgical team immediately for repair.

Review12:06–12:43

In contrast, diagnosis for stable patients involves a chest X- ray and EGD, and possibly an upper GI contrast study and a CT of the chest and abdomen.
Treatment options may include observation and medical management of GERD, as well as surgical repair with or without
Paraesophageal and hiatal hernia: Video and Causes | Osmosis