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Key Features

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  • Paraesophageal hiatal hernias (HHs)

    • Esophagus and gastroesophageal (GE) junction are in their normal anatomic position

    • However, gastric cardia is herniated through the diaphragmatic hiatus

    • Congenital paraesophageal HHs are rare in childhood

  • Sliding HHs

    • GE junction and a portion of the proximal stomach are displaced above the diaphragmatic hiatus

    • Common; correlation exists between HH and clinical symptoms of heartburn and regurgitation

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Clinical Findings

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  • Presenting symptoms

    • Recurrent pulmonary infections

    • Vomiting

    • Anemia

    • Failure to thrive

    • Dysphagia

  • Most common cause of acquired paraesophageal hernia is previous fundoplication surgery

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Diagnosis

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  • Radiographic studies typically reveal

    • Cystic mass in the posterior mediastinum

    • Dilated esophagus

  • The diagnosis is typically made with an upper GI series or a CT scan of the chest and abdomen

  • Presence of a Schatzki ring on upper GI has been found to be associated with HH in 96% of children and should increase the index of suspicion

  • Additionally, the absence of a periesophageal fat pad on CT or ultrasound of the chest has been found to be a marker of HH

  • Use of pH impedance probe testing

    • Has been proposed as an effective method to identify HH in children

    • Inversion of the usual acid:nonacid reflux ratio to > 1.0 had a sensitivity of 93.8% and specificity of 79.6%

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Treatment

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  • Surgical in symptomatic cases

  • Laparoscopic repair

    • Used more commonly than open surgical approach

    • Has been shown to have longer surgical times but a shorter time to advancement to full enteral feeding than the open surgical approach, with no change in complications

  • Controversy exists about using biosynthetic mesh for repair because it

    • Decreases the risk of recurrent hernia

    • However, also increases esophageal erosion in children

  • Fundoplication is indicated if paraesophageal or sliding HHs produce persistent symptoms, though the presence of a preoperative HH has been found to triple the risk of recurrent GERD following fundoplication

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