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1. Hiatus Hernia (for UG medical students) By Prof. Khaled Mahran MINIA UNIVERSITY

2. Introduction A hiatus hernia is a medical condition characterized by the protrusion of a part of the stomach through the diaphragm into the chest cavity. This condition occurs when the opening in the diaphragm, known as the hiatus, becomes enlarged, allowing the stomach to migrate upwards.

3. Types of Hiatus Hernia Sliding Hiatus Hernia : In this type, the junction between the esophagus and stomach slides up into the chest through the hiatus. It is the most common type of hiatus hernia. Paraesophageal Hernia : Unlike the sliding hiatus hernia, the junction between the esophagus and stomach remains in its position, but a part of the stomach pushes through the hiatus beside the esophagus. This type is less common but can be more serious.

4. Causes The exact cause of hiatus hernia is not well understood , but certain factors may increase the risk: Age : Hiatus hernia is more common in adults over the age of 50. Obesity : Excess body weight puts pressure on the diaphragm, increasing the likelihood of hernia development. Weak muscles : Weakness in the muscles surrounding the hiatus can contribute to the occurrence of hiatus hernia. Congenital factors : In some cases, individuals may be born with a larger hiatus, making them more susceptible to the condition.

5. Symptoms Heartburn : A burning sensation in the chest, often after meals or when lying down. Regurgitation : The backflow of stomach acid into the throat, leading to a sour or bitter taste. Difficulty swallowing : Sensation of food getting stuck in the chest or throat. Belching or bloating : Excessive burping or feeling bloated after eating. Extra esophageal symptoms Chest pain : Discomfort or pain in the chest area, sometimes resembling a heart attack. Voice changes and chocking Bronchitis and lung abscess

6. Diagnosis Medical History : Understanding the patient's symptoms and medical background. Physical examination : The doctor may perform a physical examination to assess the abdomen and chest. Imaging tests : barium swallow, (water siphon test in supine RPO position ) and Endoscopy may be used to visualize the hernia and assess its severity. 24 hours pHmetry Esophageal manometry

7. Barium of the H H

8. Treatment options Lifestyle modifications : Avoiding large meals, losing weight, elevating the head of the bed and avoiding lying down after meals. Avoidance of oily, sugary food, chocolate, coffee

9. Medications Antacids, Gaviscon, Maalox ( aluminium hydroxide, Magnesium hydroxide ) mucosal protecting agents (misoprostol, bismuth subsalicylate)  proton pump inhibitors Prokinetics: metoclopramide, domperidone, erythromycin, and cisapride

10. Surgery In severe cases that don't respond to other treatments, surgery may be recommended to repair the hernia and prevent future complications. *Trans thoracic ( BelsyMarck IV ) *Trans abdominal Posterior cruroplasty + fundoplication (total vs partial) Colli’s gastroplasty

11. Belsy Mark IV

12. Fundoplication

13. Colli’s gastroplasty

14. Complications of sliding HH Reflux Esophagitis Sequences of esophagitis Barrett’s esophagus Bleeding Stricture Malignancy Extra esophageal Laryngitis, Pneumonitis, pneumonia, asthma, lung abscess

15. Complications of para-esophageal HH Hemorrhage Trangulation (gastric volvulus) Obstruction Gastric stasis ulcer

16. Compications of surgery Gas bloating Dumping Dysphagia Pneumothorax Slipped wrap Accidental intestinal, gastric, esophageal injury