• Reflux and Hiatal Hernia

    by  • 30/04/2013 • Gastroenterology • 0 Comments

    1. A hiatal hernia is a herniation of the proximal stomach into the chest caused by a congenital defect in the diaphragm (rarely acquired abnormality).
    2. It predisposes to gastro-oesophageal reflux of gastric acid contents and inflammation of the distal third of the oesophagus (=reflux oesophagitis) or gastric metaplasia (=Barrett’s epithelium).
    3. Incidence: v common. Degree of symptoms do not correlate with extent of oesophagitis
    4. Pathophysiology: hiatal hernia (as described), GOR due to lifestyle factors (=obesity increasing intra-abdo pressure, smoking, stress, dietary factors [fatty foods, pastry, alcohol], all reduce pressure in lower oesophageal sphincter and so promote reflux
    5. P/c:
      1. o Heartburn (+/- nausea): Acid in mouth, worse when laying flat.
      2. o Chest pain: may be due to reflux precipitated oesophageal spasm. May present like angina – rule out cardiac cause!
      3. o Transient dysphagia: in severe oesophagitis
      4. o More persistent dysphagia with regurgitation or vomiting – suggests secondary complications such as peptic oesophageal stricture or carcinoma, bleeding (=anaemia, haematemesis, malaena), aspiration.
    6. Ix:
      1. o Upper GI endoscopy: may demonstrate oesophagitis or Barrett’s epithelium (pre-malignant condition, predisposing to lower 1/3 of oes, leads to adenocarcinoma – increased risk x 30-40. Monitor yearly with endoscopy and biopsy).
      2. o Barium swallow/meal: provides additional info to endoscopy. Can visualise motility disorders such as diffuse oesophageal spasm and achalasia. Also more accurate to show size and nature of a hiatal hernia
      3. o 24h oesophageal manometry and pH recording: used to select those patients who may benefit from anti-reflux surgery.
    7. Mx:
      1. o Lifestyle changes: cancel all described RFs, plus eating regular meals, avoiding late night eating and raising the head of the bed.
      2. o Antacids: OTC (often with alginate) are useful
      3. o H2-receptor antagonists: ranitidine
      4. o PPIs: omeprazole, lansoprazole are the most potent tx
      5. o Pro-kinetics: patients with more reflux than dyspepsia may be better tx with pro-kinetic agents (=metoclopramide, benzamide)
      6. o Surgery: useful in those whose symptoms are resistant to medical therapy, or who suffer unbearable s/e’s on PPIs (usually diarrhoea), or in those with a rolling/sliding hiatal hernia
    1. (varying amounts of stomach herniated – changeable) and high risk of incarceration/volvulus. 
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