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Endoscopic and radiologic findings of a sliding type hiatal hernia. A hiatal hernia is a portion of proximal stomach between the gastroesophageal junction (B ring; GEJ) and the diaphragmatic indentation (pinchcock action, PCA). If it is large, a hiatal hernia can be easily observed with a forward or retroflexed view during an upper gastrointestinal endoscopy (A, B) or with barium swallows (C).
Source publication
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) fe...
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Context
Impairment of esophageal motility is a common finding in patients with gastroesophageal reflux disease (GERD) as reduced lower esophageal sphincter (LES) basal pressure. A very low LES pressure might facilitate the occurrence of more gastroesophageal reflux whereas abnormal esophageal peristalsis may contribute to impaired esophageal cleara...
Citations
... Er untersuchte allerdings ein vorselektiertes gastroenterologisches Patientenkollektiv, was diesen hohen Anteil erklären könnte. Immerhin führten diese älteren Daten dazu, dass die Hiatushernie, also die Funktionsstörung im gastroösophagealen Übergang [8] mit der Folge eines Refluxes, vielerorts ursächlich für die Globussymptomatik angesehen wird. Andersherum gedacht, besteht die Vorstellung, dass bei fehlendem Herniennachweis ein Reflux als Ursache des Globus ausgeschlossen werden könne. ...
Globus pharyngeus is a common symptom with considerable suffering. Globus sensation can be caused by reflux. In many places, endoscopy of the esophagus is recommended for clarification, especially when there is a question about the presence of a hiatal hernia as the cause of reflux. Transnasal esophagogastroscopy (TNE) represents an alternative to conventional gastroesophagoscopy. It enables a quick low-complication examination of the upper aerodigestive tract in the sitting, non-sedated patient.
The aim of this work was to assess the feasibility of outpatient TNE in patients with globus sensation. Furthermore, the results of dual-probe pH monitoring were compared with the results of TNE in order to assess the value of TNE in the clarification of globus sensation and reflux.
In 30 patients with globus symptoms, 24-hour dual-probe pH monitoring and TNE were performed. In pH monitoring, reflux number, fraction time, reflux surface area index, and DeMeester score were evaluated as indicators of laryngopharyngeal reflux (LPR) and gastroesophageal reflux (GERD). Abnormalities of the esophageal mucosa and the gastroesophageal junction were recorded in TNE. The results were compared.
The TNE could be performed without any complications. Mean examination time was 5.34 ± 0.12 min. Reflux was measured in 80% of the patients (24/30) with pH monitoring. In almost half of these patients (46%), abnormalities were detected in TNE as indirect evidence of reflux. In addition to an axial hiatal hernia, these included mucosal changes such as erosive esophagitis and Barrett’s metaplasia. Patients with a hiatal hernia also suffered significantly more often from LPR than patients without a hernia (9:1).
TNE is a quick and safe examination method for diagnosing patients with an unclear globus sensation. Detection of a hiatal hernia can be seen as an indication of reflux disease. Lack of evidence of a hernia does not rule out reflux. Thus, TNE is a useful addition to pH monitoring in patients with globus sensation, because reflux-related changes in the mucosa can be recognized early and adequately treated.
... Hiatal hernias were classified into four types: type I sliding hernia is a sliding hernia (95% of all hiatal hernias) in which the gastroesophageal (GE) junction: the junction of the distal esophagus and stomach cardia) herniates above the diaphragm, type II pure paraesophageal is a paraesophageal hiatal hernia, which occurs when part of the stomach rolls up to the diaphragm through the esophagus, type III is a mixture of type I and II with the herniation of both the fundus and gastroesophageal, type IV is any structure other than the stomach herniating through the hiatus [7]. The risk factors are age, trauma, surgical history, and heredity contributing to the increase in the prevalence of paraesophageal hernia [8]. The surgical approach is recommended to treat all symptomatic paraesophageal hernias and asymptomatic larger hernias in a healthy patient under 60 years old [9]. ...
Multiple complicated concurrent hernias with obturator hernia and paraesophageal hernia unusually occur in clinical settings. The obturator hernias belong to a rare pelvic hernia that accounts for a minority of all abdominal hernias. Besides, paraesophageal hernias occur commonly in elderly female patients. Clinical manifestations of these hernias are usually unspecific and the diagnosis is based on computed tomography (CT). In this paper, we presented a case of multiple complicated hernias in an 81-year-old woman. She was admitted to our hospital due to intestinal obstruction that was caused by a simultaneous obturator and paraesophageal hernia. She was successfully treated by laparoscopic hernia repair. Postoperative progression was favorable. She was then discharged from the hospital after four hospital days.
... A contributing factor is increased intra-abdominal pressure associated with obesity, chronic constipation, chronic obstructive pulmonary disease and pregnancy. Other reported causes include trauma, advancing age, a history of surgeries in the past and genetics [3]. Interestingly, HHs have been reported to be more prevalent in Western Europe and North America and comparatively a rarer occurrence in rural Africa [4]. ...
We present a compelling case of a patient initially diagnosed with a simple sliding hiatus hernia (HH), which was managed conservatively through optimised medical therapy. Over the span of a few years, she developed new symptoms which included epigastric discomfort and pain, prompting further clinical review and imaging investigation. These revealed the progression of her HH from a simple form to a more complex rolling or para-oesophageal type. This outcome highlights the importance of recognising a potential for progression during the clinical assessment of patients with a history of reflux symptoms and the onset of new epigastric discomfort or pain. Understanding this continuum of HHs is essential for physicians as management plans may need to switch from a conservative to a more invasive approach.
... Indeed, the correlation between HH and GERD, Barrett's esophagus, and esophageal carcinoma was evaluated in multiple large-scale studies, demonstrating that HH is closely related to reflux symptoms, reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma [6][7][8]. HH patients were more likely to present with GERD symptoms, and symptomatic GERD patients were more likely to have HH than controls without symptoms [9]. Moreover, over half of the patients with reflux esophagitis had concomitant HHs, and HH was present in a great majority of patients with Barrett's esophagus [10]. ...
Hiatus hernia (HH) is a prevalent endoscopic finding in clinical practice, frequently co-occurring with esophageal disorders, yet the prevalence and degree of association remain uncertain. We aim to investigate HH’s frequency and its suspected association with esophageal disorders. We reviewed endoscopic reports of over 75,000 consecutive patients who underwent gastroscopy over 12 years in two referral centers. HH was endoscopically diagnosed. We derived data on clinical presentation and a comprehensive assessment of benign and malignant esophageal pathologies. We performed multiple regression models to identify esophageal sequela associated with HH. The overall frequency of HH was (16.8%); the majority (89.5%) had small HHs (<3 cm). Female predominance was documented in HH patients, who were significantly older than controls (61.1±16.5 vs. 52.7±20.0; P < 0.001). The outcome analysis of esophageal pathology revealed an independent association between HH, regardless of its size, and erosive reflux esophagitis (25.7% vs. 6.2%; OR = 3.8; P < 0.001) and Barrett’s esophagus (3.8% vs. 0.7%; OR = 4.7, P < 0.001). Furthermore, following rigorous age and sex matching, in conjunction with additional multivariable analyses, large HHs were associated with higher rates of benign esophageal strictures (3.6% vs. 0.3%; P < 0.001), Mallory Weiss syndrome (3.6% vs. 2.1%; P = 0.01), and incidents of food impactions (0.9% vs. 0.2%; P = 0.014). In contrast, a lower rate of achalasia was noted among this cohort (0.55% vs. 0%; P = 0.046). Besides reflux-related esophageal disorders, we outlined an association with multiple benign esophageal disorders, particularly in patients with large HHs.
... Bu nedenle Tip III, hem kayan hem de yuvarlanan HH özelliklerine sahip olan 'mikst' HH olarak adlandırılmıştır. Tip IV HH sadece mideyi sınırlamaz, proksimal midenin dışında omentum, kolon, ince barsak, periton ve dalağın göğüs boşluğuna herniasyonudur (2)(3)(4). ...
Amaç: Hiatal herni (HH); abdominal kompartmandaki mide gibi organ ve dokuların göğüs boşluğuna yerdeğiştirmesidir. HH özofagus ile diyafram arasındaki oryantasyona göre sınıflandırılır. Hastalar genellikle asemptomatik olup bazen gastrik reflü, mide bulantısı, şişkinlik, retrosternal ağrı, gastroözofagial kanama ve disfaji gibi birçok klinikle prezente olabilir. Bu çalışmada; HH olan hastaların, klinik prezentasyonunu değerlendirmek, endoskopik olarak tanısını sınıflandırarak koymak ve tedavide medikal ve invaziv olarak neler yapılabileceğini vurgulamak istedik. Gereç ve yöntemler: Bu çalışma 2021-2022 tarihleri arasında endoskopi ünitemize başvurmuş 565 hastanın gastroskopisinde HH tespit edildiği retrospektif bir çalışmadır. Gastroskopisinde HH`si olmayan ve kardia gevşekliği olan hastalar çalışmaya dahil edilmedi. Hastaların demografik özellikleri, şikayetleri, endoskopik bulguları, patolojik bulguları ve takipleri hastane veri tabanından kaydedildi. Bu veriler değerlendirilirken, istatistiksel analizler için NCSS (Number Cruncher Statistical System) 2020 Statistical Software (NCSS LLC, Kaysville, Utah, USA) programı kullanıldı. Bulgular: Çalışmamıza katılan 565 hastanın %40,2’sinin (n=227) kadın, %59,8’inin (n=338) erkekti. HH olanların yaşları 16 ile 103 arasında değişmekte olup, ortalama yaş 49,31±17,08 olarak belirlenmiştir. HH olan hastalarda sıklıkla Tip I sliding tipte HH tespit edilmiştir. Semptomatik hastalarda genellikle reflü şikayeti olup proton pompa inhibitörleri, anti-asitler, aljinat gibi ilaçlarla sıklıkla semptomatik iyileşme sağlandığı tespit edilmiştir. Sonuç: HH genellikle asemptomatik olmakla birlikte, semptomatik vakalarda ciddi klinik bir sorundur. Tip I sliding HH sıklıkla tespit edilir, bu hastalar genellikle yaşam tarzı değişikliği ve medikal tedavi ile semptomatik iyileşme sağlamaktadır. Ancak tedaviye dirençli ve komplike hastalarda endoskopik ve\veya cerrahi maniplasyonlar ile semptomatik iyileşme sağlanmaktadır.
... With these implications in mind, guidelines have recommended including axial size measurements when identifying HHs endoscopically [6,10]. Current literature investigating clinically significant HHs similarly utilize endoscopic axial length measurement when classifying the HHs [11][12][13]. However, endoscopists will often utilize subjective terms, such as "small," "medium," and "large," without any standardized objective correlations. ...
Introduction
The size of a hiatal hernia (HH) is a key determinant of the approach for surgical repair. However, endoscopists will often utilize subjective terms, such as “small,” “medium,” and “large,” without any standardized objective correlations. The aim of this study was to identify HHs described using objective axial length measurements versus subjective size allocations and compare them to their corresponding manometry and barium swallow studies.
Methods and procedures
Retrospective chart reviews were conducted on 93 patients diagnosed endoscopically with HHs between 2017 and 2021 at Newton-Wellesley Hospital. Information was collected regarding their HH subjective size assessment, axial length measurement (cm), manometry results, and barium swallow readings. Linear regression models were used to analyze the correlation between the objective endoscopic axial length measurements and manometry measurements. Ordered logistic regression models were used to correlate the ordinal endoscopic and barium swallow subjective size allocations with the continuous axial length measurements and manometry measurements.
Results
Of the 93 endoscopy reports, 42 included a subjective size estimate, 38 had axial length measurement, and 12 gave both. Of the 34 barium swallow reads, only one gave an objective HH size measurement. Axial length measurements were significantly correlated with the manometry measurements (R² = 0.0957, p = 0.049). The endoscopic subjective size estimates were also closely related to the manometry measurements (R² = 0.0543, p = 0.0164). Conversely, the subjective size estimates from barium swallow reads were not significantly correlated with the endoscopic axial length measurements (R² = 0.0143, p = 0.366), endoscopic subjective size estimates (R² = 0.0481, p = 0.0986), or the manometry measurements (R² = 0.0418, p = 0.0738). Mesh placement was significantly correlated to pre-operative endoscopic axial length measurement (p = 0.0001), endoscopic subjective size estimate (p = 0.0301), and barium swallow read (p = 0.0211). However, mesh placement was not significantly correlated with pre-operative manometry measurements (0.2227).
Conclusions
Endoscopic subjective size allocations and objective axial length measurements are associated with pre-operative objective measurements and intra-operative decisions, suggesting both can be used to guide clinical decision making. However, including axial length measurements in endoscopy reports can improve outcomes reporting.
... HHs are a common disorder in the general population, often detected by endoscopy or as an incidental finding of radiographic imaging. 2, 17 A prevalence of 13-58% in non-GERD patients and 50-94% in GERD patients has been previously reported; 18 however, a recent study by Kim et al.,2 which mainly aimed to define the prevalence of HHs in the general population, determined it to be around 9.9%, with increasing tendency in elderly patients. For their study, the authors examined CT scans performed during the Multi-Ethnic Study of Atherosclerosis. ...
Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues.
After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50–75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed.
A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 ± 3.2 vs 1.4 ± 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4–8.4, p < 0.001). At a mean follow-up time of 43.1 ± 25.0 and 43.5 ± 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 ± 10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality.
HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.
... 4 Among the different risk factors for GERD, hiatal hernia (HH) is a well-recognized anatomical predisposing condition. [5][6][7] Hiatal hernia is also a risk factor for GERD complications. It increases the risk of GERD through different mechanisms, including impaired lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, impaired esophageal acid clearance, and delayed gastric emptying. ...
... It increases the risk of GERD through different mechanisms, including impaired lower esophageal sphincter pressure, transient lower esophageal sphincter relaxation, impaired esophageal acid clearance, and delayed gastric emptying. 7 The prevalence of HH in Western populations is reportedly 14.5-22%. [8][9][10] Previous studies reported potential risk factors for HH, including older age, gender, and obesity. ...
Objectives:
To determine the prevalence of hiatal hernia (HH) and its association with age, gender, and body mass index (BMI).
Methods:
We retrospectively included patients who underwent esophagogastroduodenoscopy (EGD) at an academic tertiary care hospital. Data were collected on the presence of HH as well as patient demographics including age, gender, and BMI. Univariate and multivariate analysis were done to determine risk factors for HH.
Results:
A total of 2805 patients were included in this study. The mean age was 48.6 (±18.6) years and males constituted 28.8% of the study population. The mean BMI was 29.7 (±8.6) kg/m². The prevalence of HH was 29.8% among all patients and 48.6% among those who underwent EGD for gastroesophageal reflux disease-related indications. There was no significant association between HH and female gender (OR 1.04, 95%CI: 0.88 -1.26, p=0.53), older age (OR 0.77, 95%CI: 0.72 - 1.06, p=0.19) or BMI (OR 1.07, 95%CI: 0.9 - 1.2, p=0.39).
Conclusion:
The prevalence of HH was 28.9% based on this large endoscopy-based population. We found no association between HH and gender, age, or BMI.
... Due to the association between hiatal hernias and GERD, patients are also at risk for esophagitis, Barrett's esophagus (BE), and esophageal adenocarcinoma (EAC) [3]. Complications from unrepaired hernias include intestinal obstruction and strangulation, both of which can be very severe. ...
Esophageal hernias are anatomical defect that affects up to 50% of the population. While they may be asymptomatic, hernias may also result in reflux and dysphagia, among other symptoms. In such cases, hernia repair is warranted. The most common type of repair is laparoscopic Nissen fundoplication, which is usually well-tolerated. Herein, we present a rare case of paraesophageal hernia repair complicated by pancreatic injury and pancreatic leak.
... Hiatal hernia (HH) may be a predisposing factor for GER as it leads to separating LES and the crural diaphragm, thus decreasing their ability to cooperate as a barrier to reflux events [10,11]. Sliding HH larger than 2 cm in size is considered to be a clinically important mechanism for GER [5,12]. ...
... Esophageal dysmotility is increasingly frequently recognized in CC patients and it is regarded as an important contributor to the pathophysiology of airway reflux and cough hypersensitivity (4). HH has been shown to be closely related to reflux symptoms, reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma [12]. Besides, higher prevalence of esophageal dysmotility in patients with HH compared to subjects without HH was described [23,24] The potential pathomechanism of esophageal dysmotility is related to the decreased pressure of gastroesophageal junction due to displacement of lower esophageal sphincter and the diaphragmatic crura [25]. ...
... In the diagnosis of HH, upper gastrointestinal endoscopy, barium swallow radiography and esophageal manometry are gold standard investigations [12]. However, thoracic CT may also be considered as the one of the additional tests in diagnosis and measurement of HH [11,32]. ...
Background
Hiatal hernia may coexist with gastro-oesophageal reflux (GOR)-related chronic cough. This study aimed to evaluate whether the presence of hiatal hernia was related to chronic cough severity and the response to antireflux therapy.
Methods
This was a retrospective analysis of data on adults with GOR-related chronic cough managed in our cough centre between 2017 and 2021. Patients who had undergone chest computed tomography (CT) and in whom follow-up data were available were included. The presence and size of hiatal hernia were assessed based on thorax CT scanning. Patients were treated with modification of diet and proton pump inhibitors. The response to treatment was assessed by the change in quality of life (QOL) measured by Leicester Cough Questionnaire (LCQ) and cough severity was measured by 100-mm visual analogue scale.
Results
45 adults (28 female, 17 male) were included. Hiatal hernia was demonstrated in 12 (26.6%) patients. Patients with hiatal hernia did not differ from those without hiatal hernia in clinical characteristics, cough duration and severity and cough-related QOL. We found moderate positive correlations between maximal sagittal diameter of hiatal hernia and cough severity (ρ=0.692, p=0.013) and duration (ρ=0.720, p=0.008). Patients without hiatal hernia responded better to antireflux therapy, with significant LCQ improvement. A strong negative correlation between sagittal diameter of hiatal hernia gate and increase in LCQ (ρ= −0.764, p=0.004) was demonstrated.
Conclusion
The presence of hiatal hernia identified in chest CT may impact cough severity, duration and response to antireflux treatment in patients with GOR-related chronic cough. Further prospective studies are justified to confirm significance of hiatal hernia in the management of chronic cough.
