High incidence of dyspnoea and pulmonary aspiration in giant hiatus hernia: a previously unrecognised cause of dyspnoea.

INTRODUCTION: Dyspnoea is common in patients with giant paraoesophageal hernia (PEH). Pulmonary aspiration has not previously been recognised as a significant contributory factor. Aspiration pneumonia in association with both gastro-oesophageal reflux disease (GORD) and PEH has a high mortality rate. There is debate about routine anti-reflux measures with surgical repair. Reflux aspiration has been examined in a consecutive cohort using scintigraphic scanning and symptoms.

METHODS: Reflux aspiration scintigraphy (RASP) results and symptoms were evaluated in consecutive patients with PEH managed in our service between January 2012 and March 2017.

RESULTS: PEH was diagnosed in 96 patients. Preoperative reflux pulmonary scanning was performed in 70 patients: 54 were female (77.1%) and the mean age was 68 years (range 49-85). Dyspnoea was the most common symptom (77.1%), and a symptomatic history of aspiration was seen in 18 patients (25.7%). Clinical aspiration was confirmed by RASP in 13 of these cases. Silent RASP aspiration occurred in a further 27 patients without clinical symptoms. RASP was negative in five patients with clinical symptoms of aspiration. No aspiration by either criterion was present in 27 patients. Dysphagia was negatively related to aspiration on RASP ( p <0.01), whereas dyspnoea was not ( p =0.857).

CONCLUSION: GORD, dyspnoea and silent pulmonary aspiration are frequent occurrences in the presence of giant PEH. Subjective aspiration was the most specific and positive predictor of pulmonary aspiration. Dyspnoea in PEH patients may be caused by pulmonary aspiration, cardiac compression and gas trapping. The high rate of pulmonary aspiration in PEH patients may support anti-reflux repair.