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Chapter 4: Disorders of the oesophagus 157

Older patients and those with suspicious features should diameter of 10–15 mm. Complications include haem-
undergo endoscopy prior to commencing treatment. Al- orrhage, perforation and bacteraemia.
though H. pylori infection is no more likely to be present
in patients with gastrooesophageal reflux disease com-
Hiatus hernia
pared to the normal population, patients are tested as
part of the investigation of dyspepsia and treated if Definition
found to be positive. See also Dyspepsia and H. pylori Hiatusherniationistheabnormalpassageofpartorallof
(pages 142–162). stomach through the diaphragm. It may be axial/sliding,
Patients should be advised to lose weight if obese, and
paraesophageal/rolling or mixed.
avoid precipitating factors such as alcohol and coffee.
Raising the head of the bed may be of benefit. Prevalence
The most effective relief is provided by proton pump
Increases with age, very common in elderly patients (up
inhibitors; however, many patients have adequate to 70%).
symptom control from antacids, alginates, H 2 antag-
onists or prokinetic agents such as domperidone or Aetiology/pathophysiology
metoclopramide. An initial course of 4 weeks of treat- See Fig. 4.5.
ment is used. Ina sliding hernia the stomach passes up through its
Indications for anti-reflux surgery include continued
ownopening.Slidingherniasareinitiallyintermittent.
symptoms despite high dose proton pump inhibitor Incompetence of the lower oesophageal sphincter re-
therapy for at least 6 months, complications or high sults in reflux, which may cause chronic inflammation
grade oesophagitis in young/fit patients and reflux af- and fibrosis. This can eventually shorten the oesoph-
terprevious upper gastrointestinal tract surgery. A agus, fixing the stomach in the thorax.
fundoplication(openorlaparoscopic)isperformedin Ina para-oesophageal hernia there is a defect in the
which the mobilised gastric fundus is wrapped com- diaphragm allowing the greater curve to roll upwards
pletely or partially around the lower end of the oe- into the mediastinum. As the gastro-oesophageal
sophagus. Endoscopic techniques are now available. sphincter remains in place patients do not develop re-
Oesophageal strictures mayrequire endoscopic di- flux. Symptoms may result from pressure on the heart
latation to stretch the stricture to achieve a luminal orlungs.Thesearemostcommonlyseenintheelderly.

Oesophagus

Gastro-oesophageal Herniated
Diaphragm junction stomach

Stomach

Sliding (axial) hernia 90% Para-Oesophageal (rolling) hernia 10%
Disrupts normal anti-reflux mechanisms Anti-reflux mechanisms intact

Figure 4.5 Types of hiatus hernias.