HH is characterized by a protrusion of the upper stomach and/or abdominal viscera (other than the esophagus) into the thoracic cavity through the esophageal hiatus in the diaphragm. HH is frequently associated with gastroesophageal reflux disease (GERD) because the hiatal laxity causes gastric content and acid to back up into the esophagus. Therefore, symptoms range from heartburn, dysphagia, or regurgitation to extraesophageal symptoms such as chronic cough or asthma. HHs are most often confirmed by radiographic, endoscopic, or manometric assessment.
HH is relatively common, with a higher prevalence in the aging and overweight populations. In fact, 55% to 60% of persons older than 50 years of age have some degree of HH. However, this is variable because the majority of HHs are asymptomatic; only about 9% of patients present with symptoms. Older age and high BMI are key risk factors; other known risk factors include multiple pregnancies, history of esophageal surgery, gastrectomy, and certain disorders of the skeletal system associated with bone decalcification and degeneration.[20,21]
HHs are classified into four subtypes. Type I, or sliding HH, is the most common (>95% of cases) and is most closely associated with GERD. A sliding HH occurs when the gastroesophageal junction (GEJ) migrates up toward the hiatus, above the diaphragm. Types II, III, and IV are paraesophageal HHs. A paraesophageal HH occurs when part of the stomach herniates into the mediastinum adjacent to the esophagus while the GEJ remains in place.
Similar to inguinal hernia, the presence of hiatal hernia is not an indication for treatment; therefore, therapy is recommended only for patients who have symptoms attributable to the condition.
The management of HH depends on the type of hernia and the severity of symptoms. Similar to IH, the presence of HH is not an indication for treatment; therefore, therapy is recommended only for patients who have symptoms attributable to the condition. Management sometimes requires a multifaceted approach, including lifestyle modifications, pharmacologic therapy, surgical interventions, and endoscopic management. Most symptomatic sliding HHs are related to acid reflux; therefore, goals of treatment goals involve the alleviation of symptoms of acid reflux and the promotion of esophageal healing.
Lifestyle and dietary modifications (Table 3) are the initial step in the general treatment approach for GERD. The backbone of pharmacologic treatment constitutes medications that neutralize gastric acid, with proton pump inhibitors (PPIs) being the medications of choice (Table 4). Current guidelines recommend using the lowest possible PPI dose that will adequately control the symptoms. Alternatives include antacids and H2 receptor antagonists (H2RAs). Antacids should be used only for the relief of mild symptoms associated with GERD; this is because of their short duration of action and inability to heal erosive esophagitis. H2RAs may be effective for symptoms of mild-to-moderate GERD, but response rates vary based on disease severity, drug dose, and duration of therapy. These options may be used as needed or as add-on therapy for persistent symptoms despite PPI use. There is no evidence supporting the efficacy of prokinetic drugs in the treatment of HH associated with GERD; therefore, they are not recommended.
Paraesophageal HH often requires a different treatment approach because gastric fundal migration above the diaphragm puts patients at risk for complications such as bleeding, obstruction, and perforation. Symptomatic patients with paraesophageal HH will derive little to no relief from gastric acid–lowering medications. The definitive treatment for paraesophageal HH is surgery, either laparoscopic or open repair. Surgery may also be recommended for patients with a sliding HH who have severe or refractory symptoms and also exhibit poor medication compliance, or for younger patients who wish to avoid a lifetime of treatment. The function of surgical interventions is to correct the HH by restoring the intraabdominal esophagus, reconstructing the diaphragmatic hiatus, and reinforcing the lower esophageal sphincter.
US Pharmacist. 2022;47(6):HS-2-HS-6. © 2022 Jobson Publishing