Clinical Scorecard: The Role of Hiatus Hernia in Barrett’s Oesophagus: Insights from a Scoping Review

At a Glance

Key Highlights

• Hiatal hernia is strongly associated with the development of Barrett’s oesophagus, particularly with larger hernia sizes and long-segment BO.
• There is a possible trend towards increased dysplastic and malignant progression of BO in the presence of hiatal hernia, though evidence is inconsistent.
• Hiatal hernia may reduce the efficacy of radiofrequency ablation, with larger hernias requiring more treatment sessions.

Guideline-Based Recommendations

Diagnosis

• Assess for presence and size of hiatal hernia in patients diagnosed with Barrett’s oesophagus via endoscopy.

Management

• Consider surgical repair of hiatal hernia in selected asymptomatic patients with hernias ≥4 cm and established BO to restore anatomy and reduce reflux.
• Use proton-pump inhibitors as standard medical therapy for reflux control in BO patients.
• Radiofrequency ablation remains a treatment for dysplastic BO, but efficacy may be impaired by hiatal hernia.

Monitoring & Follow-up

• Surveillance endoscopy for BO progression, with attention to patients with hiatal hernia who may have higher risk of progression.

Risks

• Larger hiatal hernias may increase risk of BO development and possibly progression to dysplasia or adenocarcinoma.
• Hiatal hernia may lead to poorer response to endoscopic ablation therapies.

Patient & Prescribing Data

Patients with Barrett’s oesophagus and coexisting hiatal hernia

Patients with larger hiatal hernias may require more sessions of radiofrequency ablation; surgical repair may improve outcomes in selected cases.

Clinical Best Practices

• Evaluate hiatal hernia size and presence during endoscopic assessment of Barrett’s oesophagus.
• Incorporate hiatal hernia status into risk stratification for BO progression and treatment planning.
• Consider multidisciplinary approach including gastroenterology and surgery for management of BO with significant hiatal hernia.
• Monitor treatment response closely in patients with hiatal hernia undergoing ablation therapies.

References

• Shaheen NJ et al. Diagnosis and Management of Barrett’s Esophagus: An Updated ACG Guideline. Am J Gastroenterol 2022
• Wilson H et al. Fundoplication is superior to medical therapy for Barrett’s esophagus disease regression and progression: a systematic review and meta-analysis. Surg Endosc 2022
• Fitzgerald RC et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014