Hiatal Hernia

Classification: 
- Type 1: Sliding hernia - Laxity of phrenoesophageal ligament allows GE jxn to slide into chest
- Type 2: paraesophageal hernia - fundus of the stomach slides above hiatus, but GE jxn remains in the abdomen
- Type 3: Combination - GE junction above the hiatus AND fundus/body herniated into the thorax
Type 4: advanced type 3 - same but with entire stomach or other organs herniated through hiatus
There is a distinction between the terms hiatal hernia and paraesophageal hernias - all of above are hiatal hernias, however, only type 2 and 3 hernias are truly para's

Presentation:
- true incidence of type 1 hernias unknown because many asymptomatic, type 2 and 3 are very rare (<1% of hiatal hernias are type 2/3)
- often times diagnosed incidentally during investigations for other reasons
- If symptoms are present, may include reflux or mechanical symptoms of esophageal obstruction - pain, fullness, dysphagia, bloating, respiratory sx)
- Anemia: results from chronic GI blood loss in 1/3 of pts.  Caused by linear ulcerations of the gastric cardia and resolves after repair.
- Borchardt's triad: chest pain, retching with inability to vomit and inability to pass NG.  Indicative of an incarcerated hiatal hernia.


Diagnosis:
- barium swallow
- pH, manometry: may be difficult to acquire and interpret due to changes in anatomy.  May not be very useful in type 2 and 3 hernias.
- EGD

Indications for OR:
- Type 1 hernias: leave asymptomatic pts alone.  Symptomatic patients should first have symptom-specific work-up and subsequently be considered for repair.
- Asymptomatic patients: asymptomatic para's historically thought to have 30% mortality rate.  However, more recent series suggest that ~80% of pts will remain asymptomatic.
- Symptomatic patients: all symptomatic patients should be reapired.  This includes patients with esophageal mucosal changes (esophagitis, Barrett's) or anemia.