A 35-year-old man comes to the office for follow-up of an abnormal chest x-ray finding. The patient went to the emergency department 2 weeks ago after a chest injury; during a softball game, he was struck in the chest by a ball thrown from a distance of 4 feet. Initial evaluation showed no significant trauma or rib fracture, but the chest x-ray revealed an air/fluid level posterior to the cardiac silhouette consistent with a sliding hiatal hernia. The patient feels well and has had no heartburn, regurgitation, difficulty swallowing, or abdominal discomfort. He has no other medical conditions and takes no medications. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the best next step in management of this patient?

Question

A 35-year-old man comes to the office for follow-up of an abnormal chest x-ray finding.  The patient went to the emergency department 2 weeks ago after a chest injury; during a softball game, he was struck in the chest by a ball thrown from a distance of 4 feet.  Initial evaluation showed no significant trauma or rib fracture, but the chest x-ray revealed an air/fluid level posterior to the cardiac silhouette consistent with a sliding hiatal hernia.  The patient feels well and has had no heartburn, regurgitation, difficulty swallowing, or abdominal discomfort.  He has no other medical conditions and takes no medications.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient has an asymptomatic sliding hiatal hernia. The distal esophagus is attached circumferentially to the diaphragm at the esophageal hiatus by the phrenoesophageal membrane. Sliding hiatal hernias occur due to laxity of this membrane, typically in the setting of age-related degeneration or repetitive stress (eg, vomiting, coughing). This allows the gastroesophageal junction and proximal stomach to slide into the thoracic cavity. Most sliding hiatal hernias are discovered incidentally during imaging performed for other reasons. Plain radiography typically reveals a retrocardiac opacity (often with an air/fluid level) within the thoracic cavity. Although sliding hiatal hernias predispose patients to developing gastroesophageal reflux disease (GERD) (eg, heartburn, dysphagia, chest pain), asymptomatic patients require no further evaluation beyond observation. Patients with reflux symptoms should be medically managed (eg, proton pump inhibitors). Those with refractory GERD symptoms can be considered for antireflux surgery (eg, Nissen fundoplication) (Choice C). retrocardiac opacity (Choices A, B, and E) 24-hour esophageal pH monitoring can be used in the evaluation of GERD; esophageal manometry is indicated to evaluate suspected esophageal motility disorders; upper gastrointestinal endoscopy is used to visualize and intervene in a variety of gastrointestinal disorders. These procedures, as well as barium swallow (the most sensitive test for diagnosis of hiatal hernia), may be performed for further evaluation prior to surgical intervention in patients with refractory reflux symptoms. However, they are not indicated in asymptomatic patients. Educational objective: Hiatal hernia is a common disorder that occurs when the contents of the abdominal cavity herniate through the diaphragm into the thoracic cavity at the esophageal hiatus. Plain radiography typically reveals a retrocardiac opacity (often with an air/fluid level) within the thoracic cavity. Asymptomatic sliding hiatal hernias do not require further workup or intervention whereas patients with gastroesophageal reflux disease should be medically managed.

A 35-Year-Old Man Comes to the Office for Follow-Up of an Abnormal