We'll move on to our next case now.
We have a 44-year-old woman who presents for follow-up of GERD.
She was started on pantoprazole eight weeks ago when she first presented with heartburn.
She has had improvement in her heartburn symptoms during the day but continues to have heartburn causing awakenings at night.
She takes her pantoprazole 30 minutes before breakfast as directed.
Her vitals are normal, exam is unremarkable, and her chest x-ray is shown here.
What is the best next step in management?
So she has GERD treated with an adequate trial of an oral proton pump inhibitor,
she does have some symptomatic relief but continues to have persistent symptoms,
and her chest x-ray shows a mass above the diaphragm with an air-fluid level.
So let's talk a bit about hiatal hernias. There are two types of hiatal hernias.
The first type is a sliding hernia which is the most common type.
Here on this diagram, you may see that a type one hiatal hernia occurs
when part of the stomach herniates upward through the diaphragm.
On the other hand, a type two hiatal hernia occurs when part of the gastric fundus herniates upward alongside the esophagus.
So this is called a paraoesophageal hernia.
This is a higher risk condition.
Many of patients with this condition are asymptomatic
but they may also present with heartburn, chest pain, and dysphagia.
Complications may occur such as GERD, reflux esophagitis, Barrett esophagitis or malignancy, and aspiration.
The diagnosis is made by a barium swallow, an x-ray, or an upper endoscopy.
Treatment of hiatal hernias depends on the type.
So a type one hiatal hernia can often be managed with antacids and lifestyle modification to address GERD symptoms.
If the hernia is very large however or the patient develops complications then you may do a surgery called a Nissen fundoplication.
Shown here on the right is a depiction of the Nissen fundoplication.
This is when you take the fundus of the stomach, you wrap it around the back side of the esophagus and then you secure it with sutures.
This is to prevent herniation of the stomach upward into the diaphragm.
A type two hiatal hernia on the other hand, always require a surgery due to the risk of enlarging hernia.
So now let's return to our case.
We have 44-year-old woman with GERD treated with an adequate trial of a PPI, some relief from her symptoms
but she continues to have them, and this chest x-ray that shows this suspicious mass with an air-fluid level above the diaphragm.
So this appearance on her chest x-ray should prompt you to think about a large hiatal hernia.
Since she has persistent symptoms and a large hernia seen on the x-ray, you should offer surgery as the next step.