Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

upper gastrointestinal hemorrhage and/or obstruction and/or volvulus

1st line – resuscitation and urgent surgical repair

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INITIAL
|
upper gastrointestinal hemorrhage and/or obstruction and/or volvulus
1st line – 

resuscitation and urgent surgical repair

Surgical repair is indicated urgently in patients who have life-threatening conditions.[1]

Patients who can tolerate general anesthesia should undergo urgent surgical repair.

Patients who have upper gastrointestinal hemorrhage or obstruction will need resuscitation and stabilization before surgical repair.

Reduction of the intrathoracic organs and repair of the esophageal hiatus will generally resolve the complicating symptoms.

irreversible organ ischemia and/or necrosis

1st line – surgical resection and supportive care

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INITIAL
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irreversible organ ischemia and/or necrosis
1st line – 

surgical resection and supportive care

Surgical resection is urgently indicated for patients with irreversible ischemia or necrosis of the stomach or other herniated organs, such as small intestine or colon.[1]

Gastrointestinal continuity may be temporarily interrupted in these patients if a major esophagogastric resection is performed. An intrathoracic anastomosis should be avoided in frail patients who have evidence of mediastinitis. In such cases, the stomach should be stapled off and decompressed with a gastrostomy tube, and the proximal esophagus should be diverted with a cervical esophagostomy.

ACUTE

symptomatic gastroesophageal reflux disease (GERD)

1st line – proton-pump inhibitors

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ACUTE
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symptomatic gastroesophageal reflux disease (GERD)
1st line – 

proton-pump inhibitors

Patients with symptoms of GERD are treated medically with a proton-pump inhibitor (PPI). Treatment should be started with the lowest effective dose of PPI.[12][48]

Patients who respond to therapy will often need long-term maintenance treatment.

See Gastroesophageal reflux disease.

Primary options

omeprazole: 20-40 mg orally once daily for 4-8 weeks

OR

lansoprazole: 15-30 mg orally once daily for 8 weeks

OR

esomeprazole: 20-40 mg orally once daily for 4 weeks

OR

pantoprazole: 20-40 mg orally once daily for 8 weeks

OR

rabeprazole: 20 mg orally once daily for 4 weeks

Plus – lifestyle changes

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ACUTE
|
symptomatic gastroesophageal reflux disease (GERD)
Plus – 

lifestyle changes

Treatment recommended for ALL patients in selected patient group

Lifestyle modifications include losing weight, elevating the head of the bed, and avoiding large meals, meals just before bedtime, alcohol, and acidic foods.[6][12]

Substances suspected to inhibit the lower esophageal sphincter should be avoided. These include nicotine, chocolate, peppermint, caffeine, fatty foods, and drugs such as calcium-channel blockers, nitrates, and beta-blockers.

ONGOING

type I refractory to medical therapy or patient prefers surgery

1st line – surgical repair with or without antireflux procedure

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ONGOING
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type I refractory to medical therapy or patient prefers surgery
1st line – 

surgical repair with or without antireflux procedure

Referral and consideration for surgical correction is indicated in patients who have not had a satisfactory response to medical therapy.[1] This includes patients who are nonadherent with drugs, have persistent regurgitation, have reflux-induced asthma, or who simply choose to have surgical therapy.

A loose Nissen fundoplication (i.e., 360° wrap) should generally be used whenever feasible, even in patients without GERD. This practice is based on the observation that the dissection performed during a hiatal hernia repair typically destroys all of the tissue relationships that make up the physiologic antireflux mechanism. Various published opinions regarding this controversy have the support of uncontrolled data only.

Most surgical procedures for hiatal hernia now are performed with a minimally invasive (laparoscopic or robotic) approach.[13] There is a lack of randomized surgical outcome data to support the use of the robotic surgical technique. However, evidence from retrospective and prospective uncontrolled trials suggests that robotic surgery is safe, feasible, and effective, with no difference in operative times, rate of readmissions, acute complications, and with potentially lower recurrence rates compared with traditional laparoscopic surgery.[25][26][27]​ Further advantages may be seen in reoperative surgery, but more studies are needed.[28]

Both controlled and uncontrolled data indicate that the durability of a hiatal hernia repair is better if the repair is performed with prosthetic mesh.​[29][30]​​​​​​[31][32][33][34]

At this point in the evolution of hiatal hernia surgery there may be a trade-off in the choice of mesh for the repair: choose permanent mesh and there is the risk of erosion; choose biologic mesh and there is the risk of recurrence. Good scientific data to support a specific choice of mesh for the repair are currently lacking.[42][43]

Caution should be exercised when performing a laparoscopic repair of a large hiatal hernia to avoid injury to the heart or the aorta. Injury to the heart or aorta may occur secondary to suture or tacker use to anchor the mesh to the diaphragm, and may have catastrophic consequences.[44][45]

If expertise in minimally invasive surgery is not available, open repair is an acceptable alternative. Surgical correction of GERD and hiatal hernia can be performed with a combined antireflux procedure and hiatal herniorrhaphy.[13][46]

types II, III, and IV

1st line – surgical repair with or without antireflux procedure

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ONGOING
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types II, III, and IV
1st line – 

surgical repair with or without antireflux procedure

Patients with a hiatal hernia of types II to IV should be considered for surgical repair. The patient's age, comorbidities, and the long-term risk of strangulation and mediastinitis should all be considered.[1] 

The routine use of an antireflux procedure in association with the hiatal hernia repair is controversial, especially in patients who do not have signs or symptoms of gastroesophageal reflux disease (GERD) preoperatively. Guidelines suggest performing surgical fundoplication over no fundoplication, as the benefits outweigh the harms.[47]​ A loose Nissen fundoplication (i.e., 360° wrap) should generally be used whenever feasible, even in patients without GERD. This practice is based on the observation that the dissection performed during a hiatal hernia repair typically destroys all of the tissue relationships that make up the physiologic antireflux mechanism. Various published opinions regarding this controversy have the support of uncontrolled data only.

Most surgical procedures for hiatal hernia now are performed with a minimally invasive (laparoscopic or robotic) approach.[13]

There is a lack of randomized surgical outcome data to support the use of the robotic surgical technique. However, evidence from retrospective and prospective uncontrolled trials suggests that robotic surgery is safe, feasible, and effective, with no difference in operative times, rate of readmissions, acute complications, and with potentially lower recurrence rates compared with traditional laparoscopic surgery.[25][26][27] Further advantages may be seen in reoperative surgery, but more studies are needed.[28]

Both controlled and uncontrolled data indicate that the durability of a hiatal hernia repair is better if the repair is performed with prosthetic mesh.​[29][30]​​​​​​[31][32][33][34]

At this point in the evolution of hiatal hernia surgery there may be a trade-off in the choice of mesh for the repair: choose permanent mesh and there is the risk of erosion; choose biologic mesh and there is the risk of recurrence. Good scientific data to support a specific choice of mesh for the repair are currently lacking.[42][43]

Caution should be exercised when performing a laparoscopic repair of a large hiatal hernia to avoid injury to the heart or the aorta. Injury to the heart or aorta may occur secondary to suture or tacker use to anchor the mesh to the diaphragm, and may have catastrophic consequences.[44][45]

If expertise in minimally invasive surgery is not available, open repair is an acceptable alternative. Surgical correction of GERD and hiatal hernia can be performed with a combined antireflux procedure and hiatal herniorrhaphy.[13][46]

In asymptomatic patients, a shared decision-making approach should be followed to decide between surgery and observation as evidence for superiority of one over another is lacking.[38]​[47]​

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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