1. HIATAL HERNIA

2. Distal esophagus- held in position by the phrenoesophageal ligament Occurs most commonly in women Most hiatal hernias are asymptomatic 5-10% of pts. will develop GERD There is strong association with obesity Saint’s triad= gall stones+colonic diverticular disease+hiatal hernia

3. HIATAL HERNIA Type I or sliding HH: ph.-esoph. lig.intact but lax- distal esoph. and cardia herniate through the hiatus. Type II or paraesophageal HH- focal defect of the ph.- esoph. lig.- greater curvature herniates upward alongside the esoph. Type III- a combination of type I and II

4. Sliding hiatus hernia The herniated portion of the stomach can slide back and forth into and out the chest

7. Sliding HH

8. HIATAL HERNIA SYMPTOMS Type I- sy. of associated GERD Type II, III- postprandial pain, - bloating, - breathlessness with meals, - mild dysphagia The herniated gastric pouch is susceptible to volvulus, obstruction, infarction, ischemic ulcers, occult bleeding, perforation, gangrene.

9. HIATAL HERNIA DIAGNOSIS AND EVALUATION CXR- air/fluid level in post. M. on lat.view Barium swallow- the dg. study of choice Esophagoscopy- for GERD and esophagitis Manometry and pH testing for refux sy.

11. Hiatus hernia seen from below with the endoscope in an inverted position inside the stomach

12. HIATAL HERNIA MANAGEMENT Asymptomatic HH- no treatment HH+GERD- medical treatment Indications for surgery: Symptomatic HH (chest pain, dysphagia) HH+ severe esophagitis HH type II, III Oprative objectives: - reduction of hernia - closure of the hiatal defect - antireflux procedure