Medical Care: When hiatal hernias are symptomatic, acid reflux usually produces the symptoms. If the hernia itself is causing chest discomfort or other symptoms, surgery may be necessary.
" When symptoms are due to GERD, the goals of treatment include prevention of reflux of gastric contents, improved esophageal clearance, and reduction in acid production. This is achieved in the majority of patients by a combination of the following:
o Modifying lifestyle factors
o Neutralizing acid or inhibiting acid production
o Enhancing esophageal and gastric motility
" The treatment of GERD.
" Large hiatal hernias may cause iron deficiency anemia regardless of whether Cameron ulcers are present. This anemia responds well to PPI therapy with surgery offering no clear advantage over medical therapy.
Surgical Care: A patient with a large hiatal hernia may experience vague intermittent chest discomfort or pain. The paraesophageal hernia may strangulate and frequently is operated on prophylactically to prevent this complication. Paraesophageal hernias may present in infants or adults as a potentially life-threatening complication of strangulation, and prompt surgical repair is key. When found in asymptomatic individuals, laparoscopic repair is often undertaken, with large defects in the diaphragm being closed with mesh.
Surgery is necessary only in the minority of patients with complications of GERD despite aggressive treatment with proton pump inhibitors (PPIs). Because only a minority of patients with hiatal hernia have any problems, this represents a very small proportion of patients with sliding hiatal hernia; most patients with problems are managed medically.
By far, the majority of patients who would have undergone surgery in the past are managed successfully today with PPIs. However, young patients with severe or recurrent complications of GERD, such as strictures, ulcers, and bleeding, who cannot afford lifelong PPI treatment or would prefer to avoid taking medications long term, may be surgical candidates.
Another group of patients who are surgical candidates are those with pulmonary complications, in particular, asthma, recurrent aspiration pneumonia, chronic cough, or hoarseness linked to reflux disease.
Three major types of surgical procedures correct gastroesophageal reflux and repair the hernia in the process. They can be performed by open laparotomy or with laparoscopic approaches, which currently are being employed more frequently.
" Nissen fundoplication
o The Nissen fundoplication performed laparoscopically has gained popularity because of its lower morbidity and shorter hospital stay compared to the open procedure performed previously. Although a relatively high incidence of postoperative complications, such as dysphagia and gas bloating, are reported, DeMeester and Peters have shown that placing a larger bougie in the esophagus during this procedure, along with a shorter wrap and more complete mobilization of the stomach, have markedly reduced postoperative complications.
o This procedure involves a 360Β° fundic wrap around the gastroesophageal junction. The diaphragmatic hiatus also is repaired.
o A transthoracic approach may be used in patients who have had a previous Nissen wrap or those who have an irreducible hernia.
o The Toupet procedure is a variant of the Nissen wrap and involves a 180Β° wrap in an attempt to lessen the likelihood of postoperative dysphagia.
" Belsey (Mark IV) fundoplication: This operation involves a 270Β° wrap in an attempt to reduce the incidence of gas bloating and postoperative dysphagia. It also is preferred when minimal esophageal dysmotility is suspected. To complete this operation, the left and right crura of the diaphragm are approximated.
" Hill repair: In this procedure, the cardia of the stomach is anchored to the posterior abdominal areas, such as the medial arcuate ligament. This also has the effect of augmenting the angle of His and thus strengthening the antireflux mechanism.
" The antireflux procedures discussed above offer relief of symptoms in 80-90% of patients. In most cases, the procedure of choice is the one with which the surgeon is most familiar. These procedures carry low mortality and morbidity rates, lower than 15-20%. DeMeester et al found the Nissen procedure superior to the Belsey and Hill repairs with regard to symptom relief and prevention of reflux postoperatively (as judged by pH monitoring). Good long-term results have been reported for antireflux surgery, with adequate control of reflux in the range of 80% at 10 years.
" Most patients with a paraesophageal hernia remain asymptomatic. In this type of hernia, symptoms from acid reflux usually do not occur. Instead, the most common symptom is epigastric or substernal pain. Some patients complain of substernal fullness, nausea, and dysphagia.
o A significant proportion of patients with this type of hernia develop incarceration of the hernia and possible gastric volvulus, which can lead to perforation.
o If perforation occurs, the mortality rate is high. Because of this, many surgeons advise elective repair when the diagnosis is made.
o The goal of surgery is to remove the hernia sac and close the abnormally wide esophageal hiatus.
o Some surgeons then tack the stomach down in the abdomen to prevent it from migrating upwards again, or, they perform a temporary gastrostomy to help decompress the stomach and anchor it in place in the abdominal cavity.
Diet:
" An appropriate diet maintains an ideal body mass index. Obesity predisposes to reflux disease.
" Burkitt et al suggest that the Western, fiber-depleted diet leads to a state of chronic constipation and straining during bowel movement, which would explain the higher incidence of this condition in Western countries.
DRUG TREATMENT : AS FOR GERD
1. PROTON PUMP INHIBITORS:
- PANTOPRAZOLE
- RABEPAZOLE
- OMEPRAZOLE
2. ANTACIDS
3. GASTROINTESTINAL PROKINATICS :
- DOMPERIDONE
- METOCLOPRAMIDE