Hernia, Hiatal

Key Features

• 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

Clinical Findings

• Presenting symptoms

  • Recurrent pulmonary infections

  • Vomiting

  • Anemia

  • Failure to thrive

  • Dysphagia

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

Diagnosis

• 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%

Treatment

• 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