Acid clearance, hiatal hernia size and oesophagitis: redress the egress regress

Hiatal Hernia With Ulcer at the Gastroesophageal Junction Presenting With Progressive Dysphagia and Epigastric Pain: A Case Report

A hiatal hernia occurs when the contents of the abdominal cavity, most often the stomach, protrude into the chest cavity through the esophageal hiatus. The hiatus is an elliptical-shaped outlet, typically formed by parts of the right diaphragmatic crus surrounding the distal esophagus. This ailment can transpire due to either the broadening of the specific diaphragmatic opening or a shortening in the overall length of the esophagus, leading to herniation of the stomach into the thoracic region. Raised pressure in the abdominal region may also be one of the culprits. Patients with a hiatal hernia usually remain asymptomatic, but patients might have difficulty swallowing both liquids and solids in the advanced stages of the disease. The disease is rarely accompanied by reflux of gastric acid into the esophagus due to decreased activity of the lower esophageal sphincter, leading to increased complaints of epigastric pain and ulceration near the gastroesophageal junction. Long-standing cases can increase the risk of developing Barrett's esophagus with dysplasia, which may advance to esophageal carcinoma in later stages. Advanced age and obesity are significant risk factors for hiatal hernia. Obese individuals, in particular, experience higher intra-abdominal pressure, which significantly raises the likelihood of developing a hiatal hernia. The hernia may be diagnosed through an upper gastrointestinal endoscopy or radiologically through a chest X-ray in the posterior-anterior view, defining the border of the esophagus. Hence, this facilitates a more seamless and precise diagnosis. Surgical fundoplication treatment improves the patient's condition better than solitary medical management. Overall, addressing the condition surgically often yields more favorable outcomes and enhances the patient's quality of life. Hiatal hernia usually presents with no or minimal clinical manifestations. Thus, this case report highlights the importance of comprehensive clinical management of such cases.

Impact of hiatal hernia on pediatric dyspeptic symptoms

OBJECTIVES

Hiatal hernia (HH) affects from 10% to 50% of adult population. The correlation between HH, gastroesophageal reflux disease, dyspeptic symptoms, and esophagitis has long been known in adults. The primary objective of our prospective observational study was to estimate the prevalence of HH in children undergoing esophagogastroduodenoscopy (EGD), irrespective of their symptoms.

METHODS

We prospectively enrolled 111 consecutive children (48 boys and 63 girls; mean age 94.9 ± 52.3 months) referred for EGD. In all of the patients a symptomatic score assessment based on the Rome III criteria was used to measure frequency, severity, and duration of gastrointestinal symptoms. HH presence was endoscopically defined; esophagitis presence was evaluated either endoscopically and histologically. Children were divided in 2 age-range groups: <48 months (group 1) and >48 months (group 2).

RESULTS

Twenty-three patients of 111 (20.7%) had evidence of a sliding HH at EGD. In children from group 2, we found a statistically significant association of HH with heartburn (P = 0.03, 95% confidence interval 1-9.3, r = 0.1) and regurgitation (P = 0.003, 95% confidence interval 1.7-20.4, r = 0.3). Regarding esophagitis presence, no association was found at any age either with defined esophagitis or with dilated intercellular spaces.

CONCLUSIONS

Prevalence of HH in our study population was 20.7%. According to our data, HH correlates with the presence of heartburn and regurgitation in children, but not in toddlers. No association was found with esophagitis at any age.

Clinical significance of hiatal hernia

The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted "two-sphincter hypothesis." The gastroesophageal junction is an anatomically complex area with an inherent antireflux barrier function. However, the gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD. Because GERD may lead to reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma, a better understanding of this association is warranted. Hiatal hernias can be diagnosed radiographically, endoscopically or manometrically, with each modality having its own limitations, especially in the diagnosis of hiatal hernias less than 2 cm in length. In the future, high resolution manometry should be a promising method for accurately assessing the association between hiatal hernias and GERD. The treatment of a hiatal hernia is similar to the management of GERD and should be reserved for those with symptoms attributable to this condition. Surgery should be considered for those patients with refractory symptoms and for those who develop complications, such as recurrent bleeding, ulcerations or strictures.

Clinical significance of hiatal hernia

The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted "two-sphincter hypothesis." The gastroesophageal junction is an anatomically complex area with an inherent antireflux barrier function. However, the gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD. Because GERD may lead to reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma, a better understanding of this association is warranted. Hiatal hernias can be diagnosed radiographically, endoscopically or manometrically, with each modality having its own limitations, especially in the diagnosis of hiatal hernias less than 2 cm in length. In the future, high resolution manometry should be a promising method for accurately assessing the association between hiatal hernias and GERD. The treatment of a hiatal hernia is similar to the management of GERD and should be reserved for those with symptoms attributable to this condition. Surgery should be considered for those patients with refractory symptoms and for those who develop complications, such as recurrent bleeding, ulcerations or strictures.

A pro-inflammatory genotype predisposes to Barrett's esophagus

INTRODUCTION

Severity of mucosal inflammation is shown to be associated with Barrett's esophagus (BE) development in animals. It has therefore been postulated that a strong pro-inflammatory host response predisposes to BE.

AIM

To determine the impact of cytokine gene polymorphisms on the development of BE.

METHODS

The multiplex SNaPshot method was used to determine interleukin (IL)-12B (A+1188C), IL-10 (C-592A, C-819T, A-1082G), IL-8 (A-251T), IL-6 (G-174C) and IL-2 (G-330T) gene polymorphisms in 255 patients with BE and 247 patients with reflux esophagitis (RE).

RESULTS

The presence of the IL-12B C-allele, which is associated with increased IL-12p70 expression, was more frequently observed in BE than in RE patients [odds ratio (OR) 1.8; 95% confidence interval (CI) 1.2-2.7; P = 0.007). The risk of BE was increased in patients in whom the IL-12B C-allele coincided with a hiatal hernia (OR 2.9; 95% CI 1.32-6.58; P = 0.008). The IL-10(-1082) GG genotype, which is associated with higher IL-10 levels, was also associated with a decreased risk of BE when it was associated with the IL-12B C-allele, indicating IL-10-dependent down-regulation of IL-12p70 expression. A combination of the IL-12B AA genotype and the IL-10 AA or AG genotypes was associated with RE (OR 1.4; 95% CI 1.05-1.85; P = 0.011).

CONCLUSION

A genetic profile predisposing to a strong pro-inflammatory host response, mediated by IL-12p70 and partially dependent on IL-10, is associated with BE. This risk further increases when this genotype coincides with a hiatal hernia, suggesting that exposure to gastroesophageal reflux in the presence of a pro-inflammatory genetic background is a driving force in the development of BE.

The role of the hiatus hernia in gastro-oesophageal reflux disease

A sliding hiatus hernia disrupts both the anatomy and physiology of the normal antireflux mechanism. It reduces lower oesophageal sphincter length and pressure, and impairs the augmenting effects of the diaphragmatic crus. It is associated with decreased oesophageal peristalsis, increases the cross-sectional area of the oesophago-gastric junction, and acts as a reservoir allowing reflux from the hernia sac into the oesophagus during swallowing. The overall effect is that of increased oesophageal acid exposure. The presence of a hiatus hernia is associated with symptoms of gastro-oesophageal reflux, increased prevalence and severity of reflux oesophagitis, as well as Barrett's oesophagus and oesophageal adenocarcinoma. The efficacy of treatment with proton pump inhibitors is reduced. Our view on the significance of the sliding hiatus hernia in gastro-oesophageal reflux disease has changed enormously in recent decades. It was initially thought that a hiatus hernia had to be present for reflux oesophagitis to occur. Subsequently, the hiatus hernia was considered an incidental finding of little consequence. We now appreciate that the hiatus hernia has major patho-physiological effects favouring gastro-oesophageal reflux and hence contributing to oesophageal mucosal injury, particularly in patients with severe gastro-oesophageal reflux disease.