Answer Hiatal hernia

A hiatal hernia is herniation of the stomach through the oesophageal diaphragmatic hiatus into the thorax. The majority of hiatal hernias are sliding, i.e. the gastro-oesophageal junction as well as part of the stomach move up into the chest. The gastro-oesophageal junction remains correctly located in a rolling hiatal hernia and part of the stomach herniates past it up into the chest. Hiatal hernias are described as incarcerated when they are irreducible. Hiatal hernias can be diagnosed on plain chest radiographs where a gas shadow is seen projected through the cardiac silhouette. If doubt exists, then a lateral projection can be performed (Fig. 1.35). Hiatal hernias are a frequent finding on barium examinations of the upper gastrointestinal tract.

Fig. 1.36 Gastric pull-up. There has been an oesophagectomy and gastric pull-up procedure. The air fluid level is within the stomach. Note the right-sided rib changes from thoracotomy.

The appearance following oesophagectomy can also produce a large mediastinal gas shadow (sometimes with a fluid level) (see Fig. 1.36). Aspiration is a potential risk of general anaesthesia or sedation. Regional anaesthesia should be considered if appropriate for the surgery. The patient should be given an H2 antagonist or proton pump inhibitor as pre-medication. If general anaesthesia is undertaken, a rapid sequence induction with cricoid pressure should be performed and the trachea 30 intubated with a cuffed tube.

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