Synopsis
Distinguish common sliding hiatus hernia from paraoesophageal complications, manage associated reflux and escalate obstruction, volvulus or ischaemia without delay.
- A hiatus hernia occurs when abdominal viscera, usually the stomach, pass through the diaphragmatic oesophageal hiatus; many are incidental and require no hernia-specific treatment.
- Type I sliding hernia moves the gastro-oesophageal junction above the diaphragm and commonly accompanies reflux, but size and symptom severity correlate imperfectly.
- Types II to IV are paraoesophageal patterns in which the fundus or other organs herniate beside the oesophagus and can obstruct, rotate or compromise blood supply.
Key red flags
Fatigue and iron-deficiency anaemia can result from Cameron lesions, but another gastrointestinal source or malignancy must not be presumed absent.
Investigation priorities
Assess reflux injury, narrowing, mucosal bleeding and possible malignancy.
Management branches
A type I hiatus hernia accompanies uncomplicated reflux without a mechanical alarm feature.
- Confirm that chest symptoms are not cardiac and screen for dysphagia, bleeding, vomiting, anaemia and unintentional weight loss.
- Offer individual weight, meal-timing and positional measures and an evidence-based GORD medicine course rather than promising anatomical correction.
Key medicines
Proton pump inhibitorFor reflux symptoms use a licensed full-dose PPI for four or eight weeks according to NICE CG184 and the selected product, then reduce to the lowest dose that maintains control; bleeding lesions require an endoscopy-led plan.
Oral or intravenous iron replacementUse the current BNF and local iron-deficiency pathway, selecting oral or intravenous replacement from severity, tolerance, ongoing loss and urgency, with a calculated course and response review.