Short segment hiatal hernia: is it a clinically significant entity?

Association of gastroesophageal junction laxity and gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease is a prevalent condition with significant clinical variability, complicating its evaluation and treatment. The gastroesophageal flap valve is a fundamental evaluation method, but have shown limitations in specificity and reliance on subjective endoscopists' experience. Recent insights suggest that gastroesophageal junction laxity may offer an objective and quantifiable measurement for the presence of gastroesophageal reflux disease.

METHODS

This retrospective study analyzed data from 401 patients who underwent comprehensive evaluations, including a symptom questionnaire, endoscopy, pH-impedance monitoring, high-resolution manometry, and treatment directions, between January 1, 2022 and October 31, 2023. Gastroesophageal junction laxity was assessed using a modified approach based on endoscopic image analysis, with the diameter of endoscope as reference to estimate the long diameter of the laxity ring. The independent association of gastroesophageal junction laxity with pathologic acid exposure, esophagitis, and hiatal hernia were assessed by adjusting with age and sex.

RESULTS

The mean age was 44.5 ± 5.5 years old, and 49.9% (200/401) were male. The most common symptoms (≥ 1 point) were acid regurgitation (333/401, 83.0%), heartburn (315/401, 78.6%), belching (278/401, 69.3%), bloating (241/401, 60.1%), and globus sensation (241/401, 60.1%). The gastroesophageal junction laxity was significantly associated with pathologic acid exposure, esophagitis, hiatal hernia, and lower esophageal sphincter resting pressure. Notably, with the increase in gastroesophageal junction laxity, the rates of pathologic acid exposure, esophagitis, and hiatal hernia increased gradually, the lower esophageal sphincter resting pressure decreased gradually. The gastroesophageal junction laxity was independent associated with pathologic acid exposure (OR = 2.33, 95%CI 1.77-3.07, p < 0.001), esophagitis (OR = 2.10, 95%CI 1.62-2.73, p < 0.001), and hiatal hernia (high-resolution manometry: OR = 3.39, 95%CI: 2.46-4.67, p < 0.001) (endoscopy: OR = 21.65, 95%CI 11.70-40.06, p < 0.001).

CONCLUSION

The gastroesophageal junction laxity was significantly associated with the indicators of pathophysiology in gastroesophageal reflux disease.

Pelvic radiography as a non-invasive screening tool for hiatal hernia in children with cerebral palsy

The diagnosis of hiatal hernia (HH), causing severe gastroesophageal reflux disease and complications in children with cerebral palsy (CP) is cumbersome because invasive investigations are required for diagnosis. Hip displacement, one of the most common complications in children with CP, can be diagnosed with a simple pelvic radiograph. This study aimed to evaluate the association between the severity of hip displacement and HH and the diagnostic accuracy of Reimers' hip migration percentage (MP) on pelvic radiography in assessing the presence of HH. A total of 52 children with CP (27 boys, 25 girls; mean age, 6.3 years; range, 0.6-17.4 years) who underwent esophagogastroduodenoscopy, upper gastrointestinal series and pelvic radiography between March 2013 and February 2020 were recruited. Demographic and clinical characteristics, as well as endoscopic and radiological findings, were evaluated and statistically analyzed. HH was defined as ≥ 2 cm proximal displacement of the gastroesophageal junction identified in esophagogastroduodenoscopy or upper gastrointestinal series, and MP was calculated by evaluating the pelvic radiograph. Of the 52 children enrolled in this study, HH was diagnosed in 18 children (34.6%). When the patients were classified and analyzed according to the MP result, HH was observed in 10%, 26.7%, and 70.6% in MP <33%, MP 33%-39%, and MP > 40% groups, respectively (P < .001). The optimal MP cutoff of 36.5% distinguished pediatric CP patients with HH from those without HH with a sensitivity of 78%, specificity of 68%, a positive predictive value of 56.0%, and a negative predictive value of 85.2%, respectively. The application of MP and the severity of hip displacement, which can be easily measured by simple radiography, may be useful and reliable in screening for detecting HH in children with CP. Retrospectively registered. This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital (IRB No. B-2007-627-106).

Factors associated with hiatal hernia in neurologically impaired children

BACKGROUND

Hiatal hernia is clinically important because it impairs the protective mechanism that prevents gastroesophageal reflux-induced injury. Diagnosing hiatal hernia is more important in neurologically impaired children because hiatal hernia-induced gastroesophageal reflux often causes severe complications such as aspiration pneumonia or malnutrition. We aimed to evaluate the patient characteristics and early predictors of hiatal hernia in neurologically impaired children.

METHODS

We retrospectively investigated 97 neurologically impaired children who underwent esophagogastroduodenoscopy and upper gastrointestinal series between March 2004 and June 2019. Demographic and clinical characteristics, as well as endoscopic and radiological findings, were statistically analyzed.

RESULTS

Of the 97 children recruited, 22 (22.7%) had hiatal hernia. When comparing the non-hiatal hernia group with the hiatal hernia group, neurological disease longer than 6 months (odds ratio 10.9, 95% confidence interval 1.2-96.5), wasting (odds ratio 4.6, 95% confidence interval 1.3-16.3), enteral tube feeding (odds ratio 9.2, 95% confidence interval 1.6-53.0), and history of aspiration pneumonia (odds ratio 6.5, 95% confidence interval 1.2-34.5) were identified as early predictors of hiatal hernia.

CONCLUSIONS

Timely identification of predictors of developing hiatal hernia in neurologically impaired children is important for early diagnostic confirmation to initiate optimal medical or surgical treatment of hiatal hernia to avoid serious complications such as aspiration pneumonia and malnutrition.

Prevalence of Asymptomatic Hiatal Hernia in Obese Patients During Preoperative Upper Gastrointestinal Endoscopy Assessments and Correlation With Body Mass Index

Introduction In obese patients, hiatal hernia (HH) can be asymptomatic or may present with one or few symptoms, such as heartburn, nausea, or vomiting. Routine upper gastrointestinal (GI) endoscopy is the most frequent method used to determine the presence of any abnormalities, including HH. This study aimed to assess the prevalence of asymptomatic HH in obese patients during routine upper GI endoscopy assessments and to examine the correlation with body mass index (BMI). Materials and methods This was an observational, retrospective cohort study conducted at King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia. The data were extracted from the medical records and electronic charts of all obese patients who underwent preoperative upper GI endoscopy assessment between January 2017 and December 2019. Data were tabulated in Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) Version 21 (IBM Corp., Armonk, NY, USA). Results Among the 690 obese patients, HH was found in 103 (14.9%) patients. The chi-square test revealed that abdominal pain (X2=3.885; p=0.049), shortness of breath (X2=8.057; p=0.005), vomiting (X2=4.302; p=0.038), nausea (X2=4.090; p=0.043), and other HH symptoms (X2=3.897, p=0.048) were the most frequently reported HH related symptoms, but BMI was not (X2=2.126; p=0.345). In the multivariate regression model, the use of PPI (proton-pump inhibitor) medication (adjusted OR [AOR]=0.237; 95% CI=0.074-0.760; p=0.023) was found to be higher in those with HH. Vomiting (AOR=1.722; 95% CI=1.025-2.890; p=0.040) and nausea (AOR=1.698; 95% CI=1.012-2.849; p=0.045) were the most frequently reported symptoms related to HH. Conclusion Asymptomatic HH among obese patients is not widely prevalent in our region. The use of PPI medications was found to decrease the symptoms associated with HH, such as vomiting and nausea. However, there was no evidence linking BMI to the development of HH.

Cardia Laxity under Retroflexed Endoscopy Is a Reflection of Esophageal Hiatus Enlargement

Methods

Information from patients who underwent endoscopy and CT scan in our department was collected and analyzed retrospectively. Three-dimensional reconstruction of hiatus from CT images was performed using 3DSlicer software, and the degree of esophageal hiatus enlargement was compared with the degree of gastroesophageal laxity under retroflexed endoscopy.

Results

Information from 104 patients was included for analysis. The Spearman correlation coefficient was 0.617 (p ≤ 0.001). When subgroup correlation analysis was performed according to the presence of hiatal hernia on CT, the Spearman correlation coefficient was 0.816 (p ≤ 0.001) in the hernia group and 0.351 (p = 0.002) in the nonhernia group. The proportion of hiatal hernia and severe esophagitis was increasing gradually with the degree of gastroesophageal laxity.

Conclusion

The degree of gastroesophageal laxity (cardia or hiatus) under retroflexed endoscopy reflects the degree of esophageal hiatus enlargement; with the degree of gastroesophageal laxity increasing, the proportion of HH and severe esophagitis increases gradually. This may be useful for physicians in China to guide themselves in the selection of patients for endoscopic antireflux treatment.

Identifying clinically relevant sliding hiatal hernias: a population-based endoscopy study

OBJECTIVES

The clinical relevance of small to moderate sliding hiatal hernias is controversial. The aims of the present study were to (1) investigate which symptoms are associated with sliding hiatal hernias and (2) define the length of a sliding hiatal hernia at which gastrointestinal symptoms occur.

METHODS

A study population representative of the general Swedish population answered a questionnaire regarding gastrointestinal symptoms and was investigated with an upper endoscopy. The length of any sliding hiatal hernia was measured.

RESULTS

Only reflux-related symptoms were associated with length of the hiatal hernia (acid regurgitation OR 1.46, CI 1.19-1.79, heartburn OR 1.27, CI 1.05-1.54), and the association did not become significant until an axial hiatal hernia length of 2 cm.

CONCLUSIONS

Only reflux symptoms could be attributed to sliding hiatal hernias. Hiatal hernias less than 2 cm should be considered clinically insignificant.

Continuous imaging of esophagogastric junction in patients with reflux esophagitis using 320-row area detector CT: a feasibility study

BACKGROUND AND AIM

The function of the lower esophageal sphincter (LES) is evaluated using an esophageal manometric study. However, information regarding the surrounding organs is difficult to obtain with use of a sensor catheter. We investigated the utility of 320-row area detector computed tomography (CT) to evaluate morphological changes of the esophagogastric junction and surrounding organs.

METHODS

The study subjects were 18 healthy volunteers and 29 patients with reflux esophagitis (RE). Immediately after swallowing a diluted contrast agent, continuous imaging of the esophagogastric junctional area was performed for 15 s. Using CT images, the presence or absence of esophageal hiatal hernia, His angle before and after swallowing, size of the diaphragmatic hiatus, morphologically identified-LES (MI-LES) length, intraluminal horizontal area of MI-LES during relaxation phase, MI-LES thickness, abdominal esophagus length, subcutaneous fat area, visceral fat area, and esophagogastric junction fat area were evaluated.

RESULTS

Analysis of CT images showed more frequent occurrence of hiatal hernia, greater His angle, and a larger diaphragmatic hiatus in patients with severe RE, while the lengths of MI-LES and abdominal esophagus were shorter in those patients. Visceral and esophagogastric junction fat areas tended to be greater in patients with RE. In all subjects, the posterior wall of the MI-LES was thicker than the anterior wall.

CONCLUSION

Continuous imaging with 320-row area detector CT is useful to evaluate morphological changes in the esophagogastric junction area in both normal individuals and patients with reflux esophagitis.

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.