When is hiatal hernia an emergency

Abstracts were reviewed for relevancy to the topic. Studies were only included if they were published within the last 20 years, were in English, and the full text was available. In addition to the database search, references from each paper included were searched for eligible studies. Although there are rare reports of type I hiatal hernias leading to complications, official guidelines recommend that asymptomatic type I hiatal hernias should be observed only This is because the vast majority of type I hiatal hernias do not progress to the need for emergent operation without first becoming symptomatic.

It stands to reason that if such patients have regular follow-up, they will have an elective repair before they develop indications for emergency surgery. There remains of course, the unresolved question of the natural history of type I hiatal hernias and whether they eventually become type III or IV hernias. Individuals were identified using records of inpatient and outpatient health care documented in the Defense Medical Surveillance System.

In total, 27, individuals were diagnosed with a hiatal hernia during this time period, with an overall incidence of Of the 27, service members with a diagnosis of hiatal hernia, only 0. This study concluded that an overwhelming majority of diagnosed cases of diaphragmatic hiatal hernia never require surgery. The true incidence of hiatal hernia in this population was likely higher, given the fact that there was no routine screening in this study.

Unfortunately, the study did not report the distribution of different hiatal hernia types in emergent and non-emergent surgeries. Further research has examined the natural history of specifically type I hiatal hernias. A single institution retrospective review conducted by Ahmed et al. All living patients were sent a questionnaire regarding their GERD-related symptoms.

Though many patients had persistent symptoms at 10 years of follow-up, researchers discovered that only 1. Two patients received an operation due to the development of refractory GERD. One patient had progressive enlargement of the hiatal hernia and underwent elective repair secondary to the development of iron deficiency anemia. No emergency surgeries were documented over the year study period. Given the low rate of progression to surgery, authors concluded that observation of asymptomatic small to medium sized type I roman numeral hernias is safe.

There has been extensive physiologic research observing the association between sliding hiatal hernia and gastroesophageal reflux. Scheffer et al. They also compared the volume of the intraabdominal stomach using ultrasound. Researchers noted that patients with GERD symptoms had a higher proportion of time in the fasting state where they had two definitive high-pressure zones on manometry consistent with the profile of a hiatal hernia Researchers also observed that when the stomach was herniated, there was a higher rate of reflux recorded on pH testing 2.

Furthermore, there is evidence that elective repair of type I hiatal hernia is associated with lower rates of intra and post-operative complications as well as decreased complication-related reoperation rates compared to PEHs The causal association between GERD and type I hiatal hernia, plus the relatively low complication rates provide compelling evidence for elective repair of these symptomatic hernias.

An ideal research study to compare the risks and benefits of repair versus observation of symptomatic PEH would be a randomized controlled trial. However, this data is lacking given that symptomatic hernias are already routinely repaired by most surgeons. Sihvo et al. Researchers identified patients that underwent surgical treatment and 67 patients that underwent in-hospital conservative management of PEHs from — They found a 2.

In patients that were hospitalized for PEH but ultimately treated without surgery, the mortality rate was The results of this study highlight the poor outcomes of watchful waiting for symptomatic PEH. In addition to this mortality benefit, there are several well-documented symptomatic benefits to repair of PEH.

Patients often report relief of their GERD symptoms: dysphagia, bloating, regurgitation and early satiety 16 - Additional consideration should also be given to improvements in cardiac and pulmonary function.

Carrott et al. Furthermore, multivariate regression models demonstrated a correlation between the degree of PFT improvement and the amount of intrathoracic stomach. The results of this retrospective study were further corroborated in a recent prospective study of patients conducted by Wirsching et al. Low and Simchuk also found similar improvements in spirometry values In addition to improvements in respiratory function there is also research demonstrating improvements in cardiac physiology following PEH repair Together, these studies show that the improvement after PEH repair is not limited solely to gastrointestinal and GERD-related pathology.

Targarona et al. Patients were followed for a median of 24 months. Quality of life according to the GIQLI was similar between the entire cohort and a standard comparison population. The majority of recurrences were found to be asymptomatic or minimally symptomatic sliding hiatal hernias.

There was no significant difference in patient reported quality of life between groups of patients that had recurrence versus those that did not, suggesting that recurrence can be symptomatically inconsequential.

Sorial et al. At a median follow-up time of 6 months, the overall symptomatic recurrence rate was 9. They examined patient demographics, hernia size, technical aspects of the operation, and surgical experience. On multivariate analysis, experience of the operating surgeon was the only factor significantly affecting the rate of recurrence.

Mehta et al. They found a pooled 5. Their analysis found a The authors attribute this variation in part to a heterogeneous definition of recurrence Other studies have found similar favorable results 8 , 23 , 26 - These studies argue that elective surgery is safe and has favorable symptomatic outcomes. They also argue that risk of recurrence is not minimal but can be symptomatically and clinically inconsequential.

In order to determine the risk versus benefits of elective repair versus emergency surgery, a thorough understanding of the outcomes associated with emergency repair is also necessary. One such study, done by Jassim et al. Emergent repair was associated with a significantly higher rate of morbidity These differences, in part, can be explained by differing characteristics between the two groups.

Patients undergoing emergent repair were also significantly less likely to receive laparoscopic surgery. After controlling for these characteristics using multivariate analysis, emergency repair was associated with higher mortality.

These results suggest that non-elective surgery leads to poor outcomes in terms of morbidity and mortality, attributable to increased age and comorbid conditions. Multiple other studies have shown similar results. Tam et al. Ballian et al. They found that individuals undergoing emergency PEH repair were more likely to be male, older than 70, underweight or normal body weight, to have larger hernias, and increased comorbidities In this study, mortality was 1.

Polomsky et al. Fifty-three percent of the PEH hospitalizations in their study were emergent. Emergency admissions had higher mortality 2. Emergent presentation had statistical significance associated with mortality, length of stay, and cost in multivariable regression models including age and type of operative intervention.

Other studies have drawn a different conclusion: that the variance in mortality between elective and emergency repair is entirely accounted for by comorbidities. Shea et al. They compared patients undergoing emergency versus elective PEH repair, using both propensity scores and multivariate logistic regression to control for significant differences in age, sex, body mass index BMI , American Society of Anesthesiology ASA class, tobacco use, and comorbidities such as diabetes, hypertension, chronic obstructive pulmonary disease, hyperlipidemia, coronary artery disease, and GERD.

Their study identified a total of patients that underwent PEH repair, with undergoing elective repair Emergent cases were more likely to be older individuals with larger and more complex hernias.

They were also more likely to have a longer hospital stay 6. In some cases, a hiatal hernia can end up becoming strangulated or constricted. This cuts off the supply of blood, which is considered an emergency. If your doctor determines that this is a risk for you, surgery might be recommended to correct your hiatal hernia.

This helps lower the risk of a strangulated hernia. A hernia is considered an emergency if you have any signs or symptoms of a strangulated hernia. You will need to seek emergency care if this occurs. You should pay attention to any symptoms you have been experiencing. If you suspect that you have a hiatal hernia, you should see your doctor for a proper diagnosis and treatment. If you have any symptoms of a strangulated hernia, you should seek emergency medical care.

If you have symptoms of a hiatal hernia, make an appointment with Gotham Gastroenterology. Our specialists can help diagnose and offer the best treatment options. Among U. We reported a case of PEH with incarceration of stomach and colon with initial presentations of nonspecific epigastralgia and anterior chest pain.

It highlights the challenge that noncardiac chest pain presents to the ED physician. Abstract Paraesophageal hernias PEHs are hernias in which the gastroesophageal junction stays where it belongs attached at the level of the diaphragm , but part of the stomach passes or bulges into the chest beside the esophagus.

Publication types Case Reports.