PRESENTATION ON

HIATAL HERNIA
SUBMITTED TO:- SUBMITTED BY :-
MS. KALPANA BASNET NEHA GAJUREL
ROLL NO :8
B.SC NURSING 2ND YEAR
(8 TH BATCH )
 OBJECTIVES:
1. What is hiatal hernia ?
2. Types of hiatal hernia
3. Causes of hiatal hernia
4. Pathophysiology
5. Complications
6. Clinical manifestations
7. Diagnosis and Investigations
8. Treatment and Management
 What is Hiatal Hernia?
• Hiatal hernia is the protrusion of the stomach upward into
the mediastinal cavity through the esophageal hiatus of
the diaphragm.
• Normally, a portion of the esophagus and all the stomach
are situated in the abdominal cavity.
Did you see the difference?
 Types of Hiatal Hernia
1) Sliding hiatal hernia
• The sliding type, as its name implies, occurs when the
junction between the stomach and esophagus slides up
through the esophageal hiatus during moments of
increased pressure in the abdominal cavity.
• When the pressure is relieved, the stomach falls back
down with gravity to its normal position.
• Approximately 90% of all hiatal hernias are the sliding
type.
2. Paraesophageal (Rolling) hiatal hernia
• In paraesophageal hiatal there is no sliding up and down.
A portion of the stomach remains stuck in the chest cavity.
• These hernias remain in the chest at all times.
• This type is less common (<10%).
 Causes of Hiatal Hernia
Increased pressure within the abdomen caused by:
• Heavy lifting or bending over
• Frequent or hard coughing
• Hard sneezing
• Pregnancy and delivery
• Vomiting
• Constipation
• Obesity
 Causes of Hiatal Hernia contd...
Age
Smoking
Fiber-depleted diet
Chronic esophagitis
 Pathophysiology
• Congenital weakness of the diaphragm causes herniation
of the part of stomach through weakness of diaphragm
• Function of the cardiac sphincter is lost
• Regurgitation and motor dysfunction
• Reflux appears with a sliding hernia due to exposure of
LES to the low pressure in the thorax
• Obstruction , strangulation and development of the
volvulus
 Clinical Manifestation
I. The patient with Sliding hernia may have,
Heart burn
Regurgitation
Dysphagia but at least 50% are Asymptomatic
Often implicated in reflux
 Clinical Manifestation contd....
II. The patient with Paraesophageal hernia may have,
Sense of fullness or chest pain after eating or may be
asymptomatic.
Reflux does not usually occur.
Complications of hemorrhage, obstruction, and
strangulation possible.
 Complication of Hiatal Hernia
Sliding Hiatal Hernia Paraesophageal Hiatal Hernia
Most common complication is GERD. Hemorrhage

Other complications are rare and are related to Strangulation ( Gastric volvulus)
reflux Obstruction
Esophagitis (dysphagia, heartburn) Gastric stasis ulcer ( Cameron lesions- causes
Consequences of esophagitis ( peptic stricture, iron deficiency anemia)
Barrett’s esophagus, esophageal carcinoma)
Extra-esophageal complications ( pneumonitis/
pneumonia, asthma, cough, laryngitis)
INVESTIGATIONS OF SLIDING HIATAL HERNIA
• Chest X-ray
• Barium swallow
• Endoscopy
• Esophageal manometry (to measure the pressure of
LES)
• 24-48h esophageal pH monitoring to quantify reflux
• Gastroscopy with biopsy to rule out cancer and
esophagitis
 INVESTIGATIONS OF
PARAESOPHAGEAL HIATAL HERNIA
Upper Gastrointestinal Series
• Contrast solution is swallowed and X-rays are used to
identify the presence of a hiatal hernia.
Upper Endoscopy
• A gastroscope is used to evaluate the esophagus and
stomach
 Contd...
CT Scan
• Useful especially for evaluation of a paraesophageal
hernias to identify the size of the hernia and other organs
which may be involved.
 Treatment of Sliding Hiatal Hernia
LIFESTYLE MODIFICATION
• stop smoking
• weight loss
• elevate head of bed
• no meals < 3hr prior to sleeping
• smaller and more frequent meals
• avoid too much alcohol, coffee, mint and fat
MEDICAL THERAPY
• Antacids
• H2 receptor antagonists e.g. Cimetidine
• Proton pump inhibitors e.g. Omeprazole
• Prokinetic agents e.g. Metoclopramide
SURGICAL THERAPY
Indications:
• Failure of medical therapy
• Esophageal stricture
• Severe nocturnal aspiration
• Barrett’s esophagus
 Anti-reflux procedure e.g Fundoplication
• A laparoscopic
procedure in which the
fundus of the stomach is
wrapped around lower
end of esophagus.
Treatment Of Paraesophageal Hiatal Hernia
• Paraesophageal hiatal hernia is treated surgically.
Indications for surgery
• Nausea/ Vomiting
• No bowel movement
• Gastric volvulus/ Strangulation
• Severely incompetent LES
• Paraesophageal hernia
 Surgical procedures for P.H.H
• Hiatal Hernia repair
The Surgeon will;
i. Reduce the stomach and other content of the hernia into
the abdominal cavity
ii. Excise the hernia sac
iii. Repair the defect on the diaphragm
• Anti-reflux procedure e.g Fundoplication
• Gastropexy: Suturing the stomach to anterior abdominal
wall
• PEG (Percutaneous endoscopic gastrostomy): Usually in
elderly patients at high surgical risk.
 Complications Of Surgical treatment
• Intra -abdominal infection
• Esophageal perforation
• Dysphagia
• Belching difficulty
• Bloating (gas bloat syndrome)
• Self limiting within 2-4 wks, but may persist
 NURSING PROCESS

• THE PATIENT WITH AN ESOPHAGEAL CONDITION

AND REFLUX
Assessment
• Take a complete health history, including pain
assessment and nutrition assessment.
• Determine if patient appears emaciated.
• Auscultate chest to determine presence of pulmonary
complications.
 Nursing Diagnosis
• Imbalanced nutrition: less than body requirements related
to difficulty swallowing
• Risk for aspiration due to difficulty swallowing or
tubefeeding
• Acute pain related to difficulty swallowing, ingestion of
abrasive agent, a tumor, or reflux
• Deficient knowledge about the esophageal disorder,
diagnostic studies, treatments, and rehabilitation
 Planning and Goals

• Major goals may include adequate nutritional intake,

avoidance of respiratory compromise from aspiration,
relief of pain, and increased knowledge level.
 Nursing Interventions

Encouraging Adequate Nutritional Intake

• Encourage patient to eat slowly and chew all food
thoroughly.
• Recommend small, frequent feedings of nonirritating foods;
sometimes drinking liquids with food helps passage.
• Prepare food in an appealing manner to help stimulate
appetite; avoid irritants (tobacco, alcohol).
• Obtain a baseline weight, and record daily weights; assess
nutrient intake.
Decreasing Risk of Aspiration
• If patient has difficulty swallowing or handling secretions,
keep him or her in at least a semi-Fowler’s position.
• Instruct patient in the use of oral suction to decrease risk
of aspiration.
Relieving Pain
• Teach patient to eat small meals frequently (six to eight
daily).
• Advise patient to avoid any activities that increase pain
and to remain upright for 1 to 4 hours after each meal to
prevent reflux.
• Elevate the head of bed on 4- to 8-in blocks; discourage
eating before bed.
• Advise patient not to use over-the-counter antacids
because of possible rebound acidity.
• Instruct in use of prescribed antacids or histamine
antagonists.
Promoting Home- and Community-Based Care
TEACHING PATIENTS SELF-CARE
• Help patient plan for needed physical and psychological
adjustments and follow-up care if condition is chronic.
• Teach patient and family to use special equipment
(enteral or parenteral feeding devices, suction).
• Help in planning meals, using medications as prescribed,
and resuming activity.
• Educate about nutritional requirements and how to
measure the adequacy of nutrition (particularly in elderly
and debilitated patients).
CONTINUING CARE
• Arrange for home health care nursing support and
assessment when indicated.
• Teach patient to prepare blenderized or soft food if
indicated.
• Assist patient to adjust medication schedule to daily
activities when possible.
• Arrange for nutritionist, social worker, or hospice care when
indicated.
 Evaluation
Expected Patient Outcomes
• Achieves an adequate nutritional intake
• Does not aspirate or develop pneumonia
• Is free of pain or able to control pain within a tolerable
level
• Increases knowledge level of esophageal condition,
treatment, and prognosis
 REFERENCES
• B. G., Hinkle, J. L., & Cheever, K. H. (2010).
• Brunner and Siddarth’s textbook of medical-surgical
nursing (12th ed.).
• Philadelphia: Lippincott Williams & Wilkins