Approach to the Critical Patient

Immediate stabilization priorities

Airway and breathing threats

Hemodynamic assessment

Key branching decision

Uncomplicated vs complicated PEH — critical ED distinction

Borchardt's triad — diagnostic for gastric volvulus

Monitoring and escalation

Monitoring bundle

Escalation triggers

Immediate consults

Consultation triggers

History

Presenting symptoms

Core symptom complex

Acute alarm features

Symptom timeline and triggers

Timing and meal relationship

Associated symptoms

Risk factors

Demographic and lifestyle risk factors

Medical and surgical history

Prior workup and medications

Relevant prior workup

Current medications

Physical Exam

Vital signs

Hemodynamic status

Chest examination

Auscultatory findings

Respiratory work of breathing

Abdominal examination

Epigastric findings

Rectal examination

General assessment

Signs of chronic complications

Pertinent negatives

Differential Diagnosis

Life-threatening diagnoses to exclude first

Acute coronary syndrome / myocardial infarction

Aortic dissection

Esophageal perforation (Boerhaave syndrome)

Tension pneumothorax

Surgical abdominal emergencies

Gastric volvulus

Peptic ulcer perforation

Acute pancreatitis

Small bowel obstruction

Other mimics

Pulmonary embolism

Pericarditis or pericardial effusion

Diaphragmatic rupture (traumatic)

Laboratory Tests

Hematology

Complete blood count

Metabolic and chemistry panels

Basic metabolic panel

Lactate

Cardiac and hepatic markers

Troponin

Liver function tests

Coagulation and type

Coagulation studies

Type and screen

Iron studies

Iron panel and reticulocyte count

Diagnostic Tests

Scoring Systems

No validated scoring system specific to PEH in the ED

WSES severity grading for complicated diaphragmatic hernia

Chest X-Ray

Initial imaging — first-line in all acute presentations

Scoring Systems (continued 1)

HEART score — for chest pain PEH mimicking ACS

MRI

Role of MRI in PEH

CT

CT chest and abdomen with IV contrast — gold standard in ED

Ultrasound

Limited role in PEH — bowel gas limits visualization

Endoscopy and special tests

Upper endoscopy (EGD)

Barium esophagram

ECG

Disposition

Emergent admission and OR activation

Criteria for immediate OR activation

Admission criteria

Admit with surgical consultation

Level of care determination

Observation and interval surgery

Observation bridge to urgent repair

Diet advancement protocol during observation

Discharge criteria

Safe for discharge

Discharge planning

Treatment

Immediate interventions

IV access and resuscitation

Gastric decompression — first-line intervention

Nasogastric tube placement

EGD decompression if NGT fails

Pharmacological management

Acid suppression

Antiemetics

Analgesia

Antibiotics — if strangulation, perforation, or aspiration pneumonia

Surgical management

Elective laparoscopic or robotic repair — standard of care for symptomatic PEH

Urgent repair — same admission after decompression

Emergent open repair

Nonoperative management — for asymptomatic or minimally symptomatic PEH

Iron and anemia management

IV iron supplementation

Special Populations

Pregnancy

Physiologic changes affecting PEH presentation

Imaging considerations

Management modifications

Geriatric

Epidemiology in elderly

Clinical presentation differences

Management considerations

Pediatrics

Epidemiology in children

Clinical differences

Management considerations

Background

Epidemiology

Prevalence and incidence

Classification system

Outcomes data

Pathophysiology

Hernia development mechanism

Complications of untreated PEH

Respiratory and cardiac effects

Therapeutic Considerations

Evidence base for elective repair

Evidence base for urgent repair

Nonoperative considerations

Recurrence after repair

Patient Discharge Instructions

copy discharge instructions

Diagnosis: You were seen for a paraesophageal hernia (a type of hiatal hernia)

Medications

Diet and activity instructions

Activity restrictions

Follow-up instructions

Return to the emergency department immediately if you experience

References

Guidelines and key sources

American College of Surgeons — Gastrointestinal Surgical Emergencies Textbook 2021

WSES Position Paper — Management of Complicated Diaphragmatic Hernia in the Acute Setting (2023)

ACR Appropriateness Criteria — Epigastric Pain (2021)

Landmark trials and studies

Crnkovic CM et al. — Paraesophageal Hernia Repair Outcomes in Elective, Urgent, and Emergent Patient Populations

Petro CC et al. — Anterior Gastropexy for Paraesophageal Hernia Repair: A Randomized Clinical Trial

Pather K et al. — Definitive, Urgent Repair of Acutely Incarcerated Paraesophageal Hernias Is Comparable to an Elective Repair

Turner B et al. — Interval Operative Management in Patients Admitted With Acute Obstruction Due to Incarcerated Paraesophageal Hernia

Delcarro A et al. — Long-Term Outcomes of Laparoscopic Paraesophageal Hernia Repair

Lidor AO et al. — Long-term Quality of Life and Risk Factors for Recurrence After Laparoscopic Repair

Carrott PW et al. — Clinical Ramifications of Giant Paraesophageal Hernias Are Underappreciated

Dong H et al. — Risk Factors Associated With Hiatal Hernia: A Retrospective Study and Two-Sample Mendelian Randomization

Bawahab M et al. — Management of Acute Paraesophageal Hernia

Garvey EM, Ostlie DJ — Hiatal and Paraesophageal Hernia Repair in Pediatric Patients

Wo JM et al. — Clinical Features of Type III (Mixed) Paraesophageal Hernia