A Review of Inguinal and Hiatal Hernia Management

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Hiatal Hernia

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.^[18] 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.^[19] HHs are most often confirmed by radiographic, endoscopic, or manometric assessment.^[20]

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.^[19] However, this is variable because the majority of HHs are asymptomatic; only about 9% of patients present with symptoms.^[19] 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.^[22] 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.^[23]

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.^[20] Management sometimes requires a multifaceted approach, including lifestyle modifications, pharmacologic therapy, surgical interventions, and endoscopic management.^[24] 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.^[24] 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.^[25] 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.^[26] 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.^[23]

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.^[21] 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.^[20] 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.

Table 1. Nonpharmacologic Management of Inguinal Hernia
Diet	Support Device	Physical Activity
Consume fiber-rich foods such as whole grains, oats, almonds, chia seeds, avocado	A truss may be used to help retain viscera in patients with a low strangulation risk, but it does not treat the hernia Consultation with a provider for the appropriate indication and fit is crucial when a truss is being considered	Use proper technique when lifting heavy objects (i.e., bending down with the knees and lifting the object with the chest perpendicular to the floor) Maintain core strength to avoid excess strain on the abdominal musculature

Source: References 27, 28.

Table 2. Pharmacologic Management of Inguinal Hernia
Condition	Intervention	Additional Information
Chronic postoperative inguinal pain	NSAIDs (ibuprofen, naproxen)	Consult PCP if used for >10 days Consult PCP if pregnant or planning pregnancy Dosing: ibuprofen—200–400 mg po q4–6h; max 3,200 mg/day. Naproxen—200–400 mg po once, then 200 mg q8–12h prn; max dose: 400 mg in any 8–12-h period or 600 mg in a 24-h period
Chronic postoperative inguinal pain	Opioids, gabapentin, pregabalin, tricyclic antidepressants, SSRIs/SNRIs	Refer to PCP or a pain-management specialist
Smoking cessation	First-line: behavioral therapy plus varenicline (Chantix) or combination NRT: long-acting (e.g., patch) plus short-acting (e.g., gum, lozenge) or varenicline (Chantix) plus patch or bupropion SR	Interview patient using the 5A's of smoking cessation: Ask, Advise, Assess, Assist, Arrange If patient is hesitant or refuses intervention, provide smoking-cessation information: 1–800-QUIT-NOW; text "QUIT" to 47848; use mobile app quitSTART Do not use bupropion in seizure disorders
Superficial incision	I&D plus amoxicillin-clavulanate or levofloxacin or ciprofloxacin plus metronidazole	Duration: 10–14 days or until resolution of signs and symptoms of active infection Dosing: amoxicillin-clavulanate—875/125 mg po bid; levofloxacin—750 mg po daily; ciprofloxacin—500 mg po bid; metronidazole—500 mg tid

I&D: incision and drainage; max: maximum; NRT: nicotine replacement therapy; NSAID: nonsteroidal anti-inflammatory drug; PCP: primary care provider; SNRI: serotonin-norepinephrine reuptake inhibitor; SR: sustained-release; SSRI: selective serotonin reuptake inhibitor. Source: References 29–31.

Table 3. Lifestyle Modifications for Hiatal Hernia
Diet	Medication	Lifestyle
Avoid large meals and meals within 2–3 h of bedtime Remain upright during and after meals Avoid certain foods: alcohol, coffee, chocolate, carbonated beverages, onions, garlic, tomatoes, citrus, fatty foods, and spicy foods	Avoid medications that can potentiate symptoms: calcium channel blockers, beta-agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives (benzodiazepines) Take medications that can potentially irritate the esophagus with a full glass of water	Elevate head of the bed 6–8 inches or sleep on a foam wedge (pillows are not effective) Sleep on the left side Stop smoking or using tobacco products If overweight or obese, lose weight Keep a diary to track dietary, lifestyle, and medication triggers

Source: References 24, 26.

Table 4. Pharmacologic Management of Hiatal Hernia
Drug Class	Drug/Primary Ingredient	Additional Information
Proton pump inhibitor	Omeprazole (Prilosec) Lansoprazole (Prevacid) Esomeprazole (Nexium) Pantoprazole (Protonix) Dexlansoprazole (Dexilant) Rabeprazole (AcipHex)	Take 30–60 min before a meal Omeprazole, esomeprazole, lansoprazole inhibit CYP2C19 For patients aged ≥18 y
H₂ receptor antagonist	Cimetidine (Tagamet) Famotidine (Pepcid) Nizatidine (Axid AR)	Consult PCP if used >14 days May take before or after meals May reduce absorption of drugs requiring acidic environment CYP450 interactions For patients aged ≥12 y
Antacids	Magnesium hydroxide (carbonate or trisilicate) Aluminum hydroxide (phosphate) Calcium carbonate Sodium bicarbonate	For temporary relief of mild, infrequent heartburn and dyspepsia Do not take >4 times/day (or max daily dosage for specific product) Do not use regularly >14 days Take prn when symptoms start Caution: risk of bleeding with combination antacid-aspirin products May affect absorption of other medications For patients aged ≥12 y