Hiatus hernias K44.9

Heinrich Quinke was the first to describe gastroesophageal reflux, also known as GERD, in 1859 (Fisichella 2017).

A hiatal hernia (HH) is the intrusion of intestines, preferably the stomach, through the esophageal hiatus into the thoracic cavity (Kasper 2015).

Musbahi (2023), on the other hand, describes a HH merely as a normal variant and not as a disease, as this finding is seen very frequently in endoscopically examined patients (20%).

Depending on the position of the gastroesophageal junction, the upward displacement of the stomach or other organs into the thoracic cavity is divided into different subtypes:

- Preliminary stage: Cardiofundal malposition

This is a preliminary stage of axial sliding hernia. The esophagus enters the stomach at an obtuse angle due to a loosening of the cardia ligamentous apparatus (Herold 2024).

- Type I (Siewert 2006), also known as axial sliding hernia

In this case, the gastroesophageal junction and the gastric cardia are displaced cranially due to weakening of the phrenoesophageal ligament and widening of the hiatal hernia (Kasper 2015). The hernia originates from the right diaphragmatic limb (Yu 2018).

- Type II (Siewert 2006), also known as paraesophageal hernia

In paraesophageal hernia, the position and function of the lower oesophageal sphincter are normal. However, part of the stomach with a peritoneal hernia sac is pushed into the thoracic region (Herold 2024). In this case, both the right and the left muscle thigh are affected (Siewert 2006).

In this case, the cardia is always localized subphrenically due to a hernia formation next to the esophagus. The hernia sac itself is closed on all sides (Siewert 2006).

Type II tends to progress (Siewert 2006). The extreme form is the so-called "thoracic stomach", also known as the "upside-down stomach" (Herold 2024).

- Type III (Siewert 2006), also referred to as a mixed form

Type III is a combination of axial and paraesophageal HH. It usually arises from a purely axial sliding hernia in which more and more sections of the stomach shift paraesophageally through the widened hiatus over time. In contrast to a purely paraesophageal hernia, there is also an intrathoracic displacement of the cardia (Siewert 2006).

- Type IV hernias

These are when a large diaphragmatic defect also allows other abdominal organs such as the spleen or colon to enter the thoracic cavity (Siewert 2006).

Axial sliding hernia is the most common (95%) and occurs predominantly in old age (Kasper 2015) due to increasing weakness of the mesenchyme (Siewert 2006), as well as in obesity or pregnancy (Herold 2024). For example, an axial sliding hernia is found in around 50 % of the population > 50 years of age (Herold 2024). In people over the age of 70, it is even > 70 % who have an axial hiatal hernia (Siewert 2006).

The pure form of paraesophageal hiatal hernia, on the other hand, is very rare, accounting for 5% of all HH. Mixed HHs occur in 10 - 15 % of cases (Siewert 2006).

Gleithernias are caused by increased intra-abdominal pressure due to obesity, pregnancy (Kasper 2015) or pulmonary emphysema (Siewert 2006). Hereditary factors also play a role (Kasper 2015).

In 80 % of patients with type II HH, there is probably a congenital malformation: a so-called hiatus communis, i.e. a joint passage of the oesophagus and aorta through the diaphragm (Siewert 2006).

In type I, the axial sliding hernia, the sliding of the hernia can be triggered by horizontal, low body position and abdominal pressure (e.g. pressing) and is initially still reversible. As it progresses, the mesenchyme in the area of the distal esophagus becomes increasingly weak. Pregnancy, obesity and emphysema also promote hiatal hernia formation (Siewert 2006).

Disturbed abdominothoracic pressure regulation at the entrance to the stomach leads to gastroesophageal reflux with perifocal inflammation and longitudinal shrinkage of the oesophagus. As a result, the cardia is pulled further up into the mediastinum and finally successively anchored there, resulting in a fixed axial hernia (Siewert 2006).

Approximately 90% of sliding hernias are asymptomatic and are discovered incidentally during gastroscopy (Herold 2024).

- Axial sliding hernia:

The form of reflux symptoms correspond to those of the general population. However, a narrowed Schatzki ring at the upper edge of an axial hiatal hernia can be the cause of bolus obstruction by a piece of meat, known as steakhouse syndrome (Herold 2024).

- Paraesophageal hernia

In this form of hernia, a distinction is made between 3 different stages:

1. asymptomatic stage

2. uncomplicated stage: in this stage, belching and left thoracic pressure may occur

3. complication stage: In this stage there is usually chronic bleeding anemia with passage disorder, erosions or ulcers on the cord ring (so-called Cameron lesions) and incarceration (Herold 2024). Weight loss and intestinal bleeding can also occur as serious symptoms (Siewert 2006).

The diagnosis of a hiatal hernia is usually made endoscopically, supplemented by a thoracic CT scan if there is any doubt (Herold 2024).

The axial sliding hernia can be visualized very well with barium swallow radiography or by manometry. With the latter, the axial span is > 2 cm (Kahrilas 2008).

Preoperatively, the guideline recommends radiography and high-resolution manometry in addition to endoscopy (Madisch 2023).

• Gastroesophageal reflux (GERD)

The role that hiatal hernias play in this is controversial. Although most reflux patients have a hiatal hernia, the majority of patients with a hiatal hernia do not have heartburn (Kasper 2015).

• Cardiac arrhythmias
• Changes in the ECG such as
  • ST-T pattern
  • Ventricular tachycardia
  • Left bundle branch block

These changes in the ECG typically occur postprandially (Krawiek 2021)

• (very rare) cardiac arrest (Krawiek 2021)

Musbahi (2023) recommends surgical measures only in selected patients with symptomatic HH type 2 - 4, as both the recurrence rate and the need for further medical therapy are very high (see also course).

- Axial sliding hernia:

An axial sliding hernia does not require treatment, at most in the case of reflux symptoms (Herold 2024).

- Paraesophageal hernia:

Surgical treatment should be considered even in the asymptomatic stage due to the risk of complications. The procedure involves a transabdominal gastropexy with reduction and fixation of the stomach to the anterior abdominal wall (Herold 2024).

Mesh augmentation is still the subject of controversy. Nickel (2021) recommends the routine use of mesh augmentation for large hiatal hernias > 5 cm and / or in the presence of paraesophageal involvement, as both the recurrence rates and the need for complex reoperations (where there is a high risk of complications) can be reduced in these cases.

The guideline recommends adequate narrowing of the hiatus with an anterior or posterior hiatoplasty for every anti-reflux operation (Madisch 2023).

The risk of recurrence postoperatively is approx. 33 %. The need for further antacid therapy p.o. is at least 50 % (Musbahi 2023).

According to a study from 1997, the mortality rate for emergency surgery is 5.4%, with an annual risk of 1.1% (Musbahi 2023).

1. Fisichella P M (2017) Failed Anti- Reflux Therapy: Analysis of Causes and Principles of Treatment. Springer International Publishing 2
2. Herold G et al. (2024) Internal Medicine. Herold Publishing 441
3. Kahrilas P j, Kim H C, Pandolfino J E (2008) Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 22 (4) 601 - 616
4. Kasper D L, Fauci A S, Hauser S L, Longo D L, Jameson J L, Loscalzo J et al. (2015) Harrison's Principles of Internal Medicine. Mc Graw Hill Education 261, 1902 - 1903, 1906
5. Madisch A, Koop H, Miehlke S, Leers J, Lorenz P, Lynen Jansen P, Pech O, Schilling D, Labenz J (2023) S2k- Guideline Gastroesophageal reflux disease and eosinophilic esophagitis of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS). AWMF registration number 021 - 013
6. Musbahi A, Mahawar k (2023) Hiatal hernia. Br J Surg. 401 - 402 DOI: 10.1093/bjs/znac449
7. Nickel F, Cizmic A, Müller- Stich B P (2021) Mesh implantation in hiatal hernia surgery and reflux - Pro. Zentralbl Chir. 146 (02) 194 - 199
8. Siewert V, Siewert J R, Rothmund M (2006) Practice of Visceral Surgery: Gastroenterologic Surgery. Springer Medizin Verlag Heidelberg 296
9. Yu H-X, Han C- S, Xue J- R, Han Z- F, Xin H (2018) Esophageal hiatal hernia: risk, diagnosis and management. Expert Rev Gastroenterol Hepatol. 12 (4) 319 - 329