›Omeprazole 20–40 mg orally daily
›Pantoprazole 40 mg orally daily
›Antiemetics
›Ondansetron 4–8 mg IV every 6–8 hours
›First-line antiemetic
›Administer before NGT placement if vomiting active
›Metoclopramide 10 mg IV every 6–8 hours
›Prokinetic effect — use with caution, may worsen obstruction
›Avoid if complete obstruction suspected
›Prochlorperazine 10 mg IV — alternative antiemetic
›Analgesia
›IV acetaminophen 1000 mg every 6 hours
›First-line for pain management — avoids opioid side effects
›IV morphine 2–4 mg every 4–6 hours as needed
›Use with caution — opioids worsen gastric dysmotility
›Avoid if complete obstruction suspected
›Ketorolac 15–30 mg IV — caution with Cameron ulcers
›Antibiotics — if strangulation, perforation, or aspiration pneumonia
›Piperacillin-tazobactam 3.375 g IV every 6 hours
›Covers gram-negative and anaerobic organisms
›First-line for perforation or strangulation
›Meropenem 1 g IV every 8 hours
›Severe sepsis or ESBL concern
›Ceftriaxone 1–2 g IV daily plus metronidazole 500 mg IV every 8 hours
›Alternative for aspiration pneumonia with anaerobic coverage
›Elective laparoscopic or robotic repair — standard of care for symptomatic PEH
›Hernia reduction and sac excision
›Crural closure — primary closure preferred
›Mesh reinforcement reduces recurrence
›3.9% recurrence with mesh vs 66.7% without
›Biosynthetic mesh preferred for hiatal reinforcement
›Fundoplication — performed in most cases regardless of manometry
›Nissen (360 degree) most common — 52% of cases
›Partial fundoplication (Toupet or Dor) if dysmotility present
›Partial preferred if manometry not performed preoperatively
›Anterior gastropexy — improves anatomical stability, reduces recurrence
›RCT (JAMA Surgery 2025) supports anterior gastropexy addition
›Urgent repair — same admission after decompression
›Outcomes comparable to elective repair
›Preferred over prolonged observation in good surgical candidates
›Emergent open repair
›Reserved for perforation, necrosis, or hemodynamic instability
›Mortality 6.7% vs <1% elective
›Damage control approach if physiologically decompensated
›Nonoperative management — for asymptomatic or minimally symptomatic PEH
›Risk of strangulation lower than operative morbidity in this population
›Annual surveillance and symptom monitoring
›Reassess if symptoms develop or progress
Iron and anemia management
›IV iron supplementation
›Iron sucrose 200–300 mg IV over 30–60 minutes
›Ferric carboxymaltose 500–1000 mg IV alternatively
›Preferred preoperatively to optimize hemoglobin
›Target Hgb >= 100 g/l before elective surgery
›Blood transfusion if Hgb < 70 g/l or symptomatic anemia
›Threshold Hgb < 80 g/l if cardiac comorbidity