Definition
A.The hiatal hernia occurs when portions of the stomach or other abdominal cavity organs herniate through the esophageal hiatal of the diaphragm. The patient may be asymptomic, and the herniation may be found incidentally in the diagnostic evaluation of other problems. There are four types of hiatal hernia:
1.Type I: Sliding hernia. A portion of the stomach, gastroesophageal (GE) junction, slides in and out of the hiatus. The fundus of the stomach remains below the GE junction.
2.Type II: Paraesophageal hernia. The gastric fundus of the stomach slides through the hiatus and lies next to the esophagus.
3.Type III: Combined. Combination of sliding and paraesophageal hiatus hernia
4.Type IV: Complex paraesophageal hernia. The stomach, small and large bowels, spleen, pancreas, or liver are pushed up into the chest through a large defect.
Incidence
A.The frequency of hiatal hernias increase with age, from 10% in patients younger than 40 years to 70% in patients older than 70 years.
B.Gender: Hiatal hernias are more common in women.
C.The most common hiatal hernia is the type I sliding hernia (95%).
D.Type II through type IV hernias make up the remaining 5% and are referred to as paraesophageal hernias (PEH).
E.The least common herniation is type II.
Pathogenesis
A.The exact cause of a hiatal hernia is unknown. It is known for the widening of the GE junction and/or laxity of the phrenoesophageal (gastrosplenic and gastrocolic ligaments). A hiatal hernia may also be a congenital defect.
Predisposing Factors
A.Obesity.
B.Pregnancy.
Common Complaints
A.Asymptomic (found incidentally, on upper endoscopy or other radiographic imaging being performed for other problems).
B.Heartburn.
C.Upper abdominal pain.
D.Vague, intermittent chest discomfort or pain.
E.GE reflux or acid brash.
F.Trouble swallowing.
G.Choking.
Other Signs and Symptoms
A.Burping.
B.Hiccups.
C.Coughing.
D.Vomiting blood.
E.Blood in stools.
F.Weight loss.
Potential Complications
A.Strangulation/incarceration.
B.Gastric volvulus.
C.Perforation.
D.Respiratory compromise secondary to the hernia.
Subjective Data
A.Ask patient what activity brought about or preceded the episode.
B.What are alleviating and aggravating factors?
C.Review medical history for a diagnosis of gastroesophageal reflux disease (GERD):
1.If the patient has a diagnosis of GERD, has the patient been prescribed and is he or she taking proton pump inhibitors (PPIs)?
2.Has the patient had an esophagogastroduodenoscopy (EGD)? Was a hiatal hernia noted at the time of the procedure?
D.Review medical history for cardiac diagnosis.
E.Ask patient to list all medications currently being taken, including herbals and over-the-counter (OTC) medications. Specifically review whether the patient is taking OTC antacids, H2 blockers, or OTC PPIs.
Physical Examination
A.Check pulse, respirations, and blood pressure (BP). Measure height and weight to calculate body mass index (BMI).
B.Inspect:
1.Inspect general appearance and observation of respiration, noting any distress.
2.Assess swallowing ability.
C.Auscultate:
1.Auscultate abdomen in all four quadrants.
2.Conduct a complete heart and lung exam.
D.Palpate:
1.Palpate upper gastric region for tenderness or distension.
2.Palpate abdomen for organomegaly or masses.
E.Perform a rectal examination (if indicated for hematemesis or blood in the stool).
Diagnostic Tests
The 2013 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines recommend tests should be done to diagnose hiatal hernia only if they will change clinical outcome.
A.Barium swallow (identifies anatomy and size of hernia).
B.Esophagogastroduodenoscopy (EGD).
C.High-resolution manometry.
D.CT scan.
E.Large hiatal hernias may cause iron deficiency anemia:
1.Complete blood count (CBC).
2.Iron.
3.Ferritin.
Differential Diagnoses
A.Hiatal hernia.
B.GERD.
C.Cholecystitis.
D.Esophageal spasm.
E.Angina pectoris.
F.Coronary artery disease.
G.Cancer (gastric or esophageal).
Plan
A.General interventions:
1.Management depends on the cause and severity of symptoms. Asymptomatic sliding hernias do not require surgical repair. Management of sliding hernias with reflux include managing symptoms of GERD.
B.Patient teaching:
1.Educate patient about modifying controllable risk factors such as keeping diabetes and hypertension under control, diet, exercise, and stopping smoking.
C.Dietary management:
1.There is no specific diet for a hiatus hernia; however, dietary modifications for GERD are encouraged.
2.Food should be cut up into small bite-size pieces and thoroughly chewed.
D.Pharmaceutical therapy:
1.There is no medication specific for a hiatal hernia; however symptomatic acid reflux can be treated by neutralizing acid with antacids or by blocking acid secretion with H2-receptor blocking agents for more potent PPIs:
a.PPIs increase the risk of Clostridioides difficile infection.
b.PPIs are associated with bone loss and fractures.
E.Medical and surgical management:
1.Surgical repair is not indicated in the absence of reflux disease.
2.Age and patient comorbidities should be considered in the routine elective repair of completely asymptomatic PEH.
3.The SAGES guidelines recommend that, during operations for Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, and placement of adjustable gastric bands, all hiatal hernias should be repaired.
4.All symptomatic types II to IV PEH should be repaired, especially in the presence of acute obstructive symptoms or volvulus:
a.There are three major types of surgical repair: Nissen fundoplication, Belsey fundoplication, and a Hill repair. These procedures offer relief in 80% to 90% of patients.
Follow-Up
A.Follow-up is determined by patient’s needs, severity of symptoms, and whether complications are present.
Emergent Issues/Instructions
An emergent surgical repair of a hiatal hernia is required in patients with a gastric volvulus, uncontrolled bleeding, obstruction, strangulation, perforation, and respiratory compromise.
Consultation/Referral
A.Consider a surgical consultation for hiatus repair for:
1.Patients who have no relief from PPIs.
2.Pulmonary complications that are linked to GERD, including asthma and recurrent aspiration pneumonia.
Individual Considerations
A.Pregnancy: The incidence of a hiatal hernia increases due to the increase in intraabdominal pressure from the uterus.
B.Geriatrics:
1.For the older adult with existing GERD, nurse practitioner (NPs) should practice special consideration of the following geriatric syndromes:
a.Falls:
i.Consistently assess for falls. PPIs are associated with osteopenia/osteoporosis.
ii.At the minimum, older adults should be asked how many times they have fallen since their last visit. A reported fall should trigger questions about whether the fall led to injury, a visit to urgent care or hospital ED, or a hospital admission.
iii.
See Section III: Patient Teaching Guide Safety Issues: Fall Prevention.
b.Weight loss/appetite suppression: Weight loss is a predictor of mortality. Clinically significant weight loss is considered to be 5% loss of usual body weight in 3 months or 10% in 6 months.
c.Because of gastrointestinal (GI) distress, abdominal discomfort, and diarrhea the elderly patient is at increased risk of avoiding eating.
d.Monitor weight patterns/BMI. (Caution: BMI is not used to identify loss of muscle mass.)
e.Monitoring both serum albumin and anemia: Hypoalbuminemia and anemia is not necessarily associated with low bodyweight. It can be caused by decreases in liver protein synthesis:
i.Serum albumin concentration is commonly recommended.
ii.Hemoglobin (Hgb), prealbumin, and transferrin.
iii.Cholesterol.
2.Beers Criteria cautions for PPIs:
a.Due to polypharmacy a full review of medications, herbals, and OTC drugs should be undertaken to identify mediations that increase symptoms of GERD, medications that should be avoided in the geriatric population, duplicate medications, and medications that are able to be to be decreased or deprescribed. (Refer to section Deprescribing
of Chapter 3.)
b.Prescribe the lowest dose for the shortest amount of time.
c.PPIs are on the American Geriatrics Society 2015 Beers Criteria for potential inappropriate medications use in older adults. (Refer to Appendix C: Beers Criteria, Table C.1.) Avoid scheduled use of PPIs for greater than 8 weeks unless needed for high-risk patients. PPIs are associated with the following:
i.Osteoporosis/osteopenia, prolonged exposure may increase of fractures.
ii.Community-acquired pneumonia.
iii.C. difficile infections and diarrhea.
iv.Vitamin B12 deficiency and hypomagnesium.
d.See Appendix D for the PPI Deprescribing Algorithm from deprescribing.org.