FIGURE 4 - uploaded by Sjirk J Westra
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Nonfixed sliding hiatal hernia of distal esophagus with reflux. (A) Long intra-abdominal part of esophagus, EL-2.4 crn (between arrowheads), slightly rounded GEA (compare with Figure 1A). (B) after upward sliding of distal esophagus, a prominent beak (curved arrow) is noted at the gastroesophageal junction, just preceding (C) reflux (large arrow). (D) Barium esophagograrn: rounded GEA (compare with Figure 16). normal infradiaphragmatic length of esophagus. (E) With the water siphon test, a beak at GEA (curved arrow) and reflux are indicated.
Source publication
In 30 young children suspected of gastroesophageal reflux (GER), the G–E junction was examined with ultrasonography directly after a feeding while these children were on overnight extended esophageal pH monitoring (EEpHM) (32 simultaneous ultrasound/EEpHM studies). The two tests showed 81% to 84% agreement in the detection of the presence or absenc...
Contexts in source publication
Context 1
... alternate during the study period (15 stud- ies; Figure 4). With UGS, a beak at the G-E junction was demonstrated, often only during the water siphon test (Figure 4D,E). ...
Context 2
... alternate during the study period (15 stud- ies; Figure 4). With UGS, a beak at the G-E junction was demonstrated, often only during the water siphon test (Figure 4D,E). In 12 of the 15 studies where these criteria applied, reflux was seen with ultrasonography only while the "hernia" was present, and in some the distal esophagus was seen to actually slide up through diaphragmatic hiatus just before reflux occurred. ...
Citations
... The technique for visualizing the abdominal and lower thoracic esophagus with ultrasonography is a well-established method that aids in the diagnosis of gastroesophageal reflux disease and hiatal hernia in infants and children. 14,15 Using this technique, we were able to detect and observe the time course of the collection of air and fluid in the posterior mediastinum of the ELBWI with esophageal perforation. The technique for visualizing the lower part of the esophagus was also practicable for nonexperts. ...
Esophageal perforation in premature infants is a life-threatening condition that requires prompt treatment. Contrast-enhanced computed tomography (CECT) is recommended for diagnosis. However, it is difficult to obtain CECT images in premature infants because of their unstable conditions. We encountered a case of esophageal perforation in an extremely-low-birth-weight female infant. Bedside ultrasonography was useful in the diagnosis and follow-up evaluation of leakage in the mediastinum. Ultrasonography can be a useful modality for the evaluation of perforation of the lower part of the esophagus in premature infants.
... The overall incidence is about 10%-50% [2] , and type I is the most common form, accounting for more than 85% of overall cases [1] . Clinically, diagnostic methods for EHH include radiography, endoscopy, esophageal manometry [4] , pH measurement [3] , and ultrasonography [5] . However, each of these techniques has shortcomings and limitations, such as radiation exposure, more invasiveness, difficulty in finding small and sliding hernias, and inconclusive diagnosis for small EHH. ...
Background:
Due to a thicker abdominal wall in some patients, ultrasound artifacts from gastrointestinal gas and surrounding tissues can interfere with routine ultrasound examination, precluding its ability to display or clearly show the structure of a hernial sac (HS) and thereby diminishing diagnostic performance for esophageal hiatal hernia (EHH). Contrast-enhanced ultrasound (CEUS) imaging using an oral agent mixture allows for clear and intuitive identification of an EHH sac and dynamic observation of esophageal reflux.
Case summary:
In this case series, we report three patients with clinically-suspected EHH, including two females and one male with an average age of 67.3 ± 16.4 years. CEUS was administered with an oral agent mixture (microbubble-based SonoVue and gastrointestinal contrast agent) and identified a direct sign of supradiaphragmatic HS (containing the hyperechoic agent) and indirect signs [e.g., widening of esophageal hiatus, hyperechoic mixture agent continuously or intermittently reflux flowing back and forth from the stomach into the supradiaphragmatic HS, and esophagus-gastric echo ring (i.e., the "EG" ring) seen above the diaphragm]. All three cases received a definitive diagnosis of EHH by esophageal manometry and gastroscopy. Two lesions resolved upon drug treatment and one required surgery. The recurrence rate in follow-up was 0%. The data from these cases suggest that the new non-invasive examination method may greatly improve the diagnosis of EHH.
Conclusion:
CEUS with the oral agent mixture can facilitate clear and intuitive identification of HS and dynamic observation of esophageal reflux.
... For GERD diagnosis, ultrasonography is not indicated, as the results are obviously investigator-dependent. Ultrasound sensitivity is around 95 percent in the 15 minutes postprandial, but the accuracy is just 11 percent compared to pH-metry [9,10]. The correlation between the thickness of the esophageal wall and esophagitis is also weak. ...
It remains a challenge to diagnose and treat gastro-esophageal reflux (GER) and GER disease (GERD) in infants and children. Together with Embase, MEDLINE, and the Cochrane Database, the published guidelines and position papers were reviewed and summarized in order to suggest a realistic GER and GERD strategy and management for healthcare providers and to standardize and enhance the quality of care for infants and children. Two algorithms were developed for this purpose, 1 for infants <12 months of age and the other for older children. None of the signs and symptoms of GER and GERD are unique and there is no screening test or tool for a gold standard. As a first-line approach, nutritional management is recommended in babies, while for early management, a clinical trial with antacid medication is recommended in children. The aim of the realistic recommendations of this review is to optimize GER management in infants and older children and to minimize the number of investigations and the improper use of medication. Keywords: Gastro-esophageal reflux, Gastroesophageal reflux disease, Esophagitis, Endoscopy, Impedance, Proton pump inhibitors, pH.
... Ultrasonography is not indicated for GERD diagnosis as the results are clearly investigator-dependent. The sensitivity of ultrasound in the 15 minutes postprandial is about 95% but the specificity is only 11% in comparison to pH-metry [9,10]. The correlation between esophageal wall thickness and esophagitis is also poor. ...
The diagnosis and management of gastro-esophageal reflux (GER) and GER disease (GERD) in infants and children remains a challenge. Published guidelines and position papers, along with Embase, MEDLINE, and the Cochrane Database were reviewed and summarized with the intent to propose a practical approach and management of GER and GERD for healthcare providers and to standardize and improve the quality of care for infants and children. For this purpose, 2 algorithms were developed, 1 for infants <12 months of age and the other for older children. None of the signs and symptoms of GER and GERD are specific and there is no gold standard diagnostic test or tool. Nutritional management is recommended as a first-line approach in infants, while in children, a therapeutic trial with antacid medication is advised for early management. The practical recommendations from this review are intended to optimize the management of GER in infants and older children and reduce the number of investigations and inappropriate use of medication.
... Absence of paraesophageal fat may be a more reliable indicator than hiatal widening because it is not affected by age, obesity, or BMI [46] . Although ultrasound is not recommended for evaluation of GERD, it can be used in cases of unusual posturing or aspiration, because episodes of retrograde passage of gastric contents detected on ultrasound can be correlated temporally with symptoms [47,48] . It can be helpful to detect GERD in an infant with suspected HPS and a normal pylorus. ...
... It can be helpful to detect GERD in an infant with suspected HPS and a normal pylorus. A short intra-abdominal segment of esophagus and/or a wide esophageal angle have been shown to be associated with reflux [48,49] . Duodenal intramural hematoma: Duodenal hematomas in children are typically post-traumatic. ...
Ultrasound is an invaluable imaging modality in the evaluation of pediatric gastrointestinal pathology; it can provide real-time evaluation of the bowel without the need for sedation or intravenous contrast. Recent improvements in ultrasound technique can be utilized to improve detection of bowel pathology in children: Higher resolution probes, color Doppler, harmonic and panoramic imaging are excellent tools in this setting. Graded compression and cine clips provide dynamic information and oral and intravenous contrast agents aid in detection of bowel wall pathology. Ultrasound of the bowel in children is typically a targeted exam; common indications include evaluation for appendicitis, pyloric stenosis and intussusception. Bowel abnormalities that are detected prenatally can be evaluated after birth with ultrasound. Likewise, acquired conditions such as bowel hematoma, bowel infections and hernias can be detected with ultrasound. Rare bowel neoplasms, vascular disorders and foreign bodies may first be detected with sonography, as well. At some centers, comprehensive exams of the gastrointestinal tract are performed on children with inflammatory bowel disease and celiac disease to evaluate for disease activity or to confirm the diagnosis. The goal of this article is to review up-to-date imaging techniques, normal sonographic anatomy, and characteristic sonographic features of common and uncommon disorders affecting the gastrointestinal tract in children.
... Nemati et al found that the mean length of the subdiaphragmatic esophagus in the patients with GERD was significantly shorter than controls; moreover, children with severe reflux had a shorter esophagus [31]. Other studies confirmed their findings [12,32,33]. In our study, although the IAEL did not significantly correlate with the severity of reflux in BS, we found that the IAEL was shorter in normal comparing with mild and moderate BS. ...
... Even though not correlated significantly with the severity of reflux in BS, our results could be used in the future studies. In a study undertaken by Westra et al [33], the gastroesophageal junctions of 30 young children proven to have GERD were examined with US. The authors described a rounded gastroesophageal angle associated with significant GERD. ...
Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal pathology in infants and young children. Ultrasonography (US) has been considered to be a reliable diagnostic tool for GERD but the severity of GERD and the clinical implications based on imaging findings has not been evaluated.
To compare the diagnostic value of lower esophageal US with that of barium swallow in demonstrating the severity of GERD.
Fifty one pediatric patients, age between 1 month to 12 years, 34 male and 17 female with clinical suspicion of GERD were included. The patients were initially submitted to barium swallow (BS) and subsequently to transabdominal US. During BS, the number of gastroesophageal reflux episodes was documented in a 5-minute period. Transabdominal US documented the number and duration of reflux episodes during a 5-minute period, the angle of His, mucosal thickness, and intraabdominal esophageal length (IAEL).
Duration and number of reflux episodes in US were significantly higher in patients that had severe gastroesophageal refluxes at BS. At US the cutoff point of 9.5 seconds (sensitivity 80%, specificity 60%) for reflux duration and more than 2 episodes in 5 minute ultrasound study (sensitivity 75%, specificity 58%) were defined to correlate with severe gastroesophageal reflux at BS.The angle of His, the esophageal wall mucosal thickness, and the IAEL did not correlate with the severity of GERD detected in BS.
US can predict the severity of GERD. Therefore, except in the case of specific patients in whom mechanical causes are suspected to be responsible for GERD, BS can be replaced by US.
... According to the guidelines, US is not recommended as a test for GERD but can provide information not available through any other technology, allowing the exclusion of non-GER causes of symptoms, such as hypertrophic pyloric stenosis, hiatus hernia, and abdominal mass. Nevertheless, when compared with the results of 24-h esophageal pH testing, the sensitivity of color Doppler ultrasound, performed for 15 min postprandially, is about 95 % with a specificity of only 11 %, and there is no correlation between reflux frequency detected by ultrasound and reflux index detected by pH monitoring [7,24] [11]. The other major violation of the guidelines concerns the therapeutic approach to GER. ...
Unlabelled:
The aim of the present study was to investigate the current approach of Italian general pediatricians to children with gastroesophageal reflux (GER) symptoms, evaluating the implementation of the 2009 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)-European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) guidelines. One hundred randomly identified Italian general pediatricians were asked to complete a case report-structured questionnaire investigating their approach to infants, children, and adolescents with symptoms suggestive of GER. Only 2 % of them showed complete adherence to the guidelines. Thirty-nine percent of them diagnosed GER disease based on clinical symptoms, irrespective of the age of the child; 56 % prescribed proton pump inhibitors (PPIs) in infants with unexplained crying and/or distressed behavior and 38 % in infants with uncomplicated recurrent regurgitation and vomiting; 57 % prescribed PPIs in children younger than 8-12 years of age with vomiting and heartburn, without specific testing; and 54 % discontinued PPI therapy abruptly. The overall rate of pediatricians over-prescribing PPIs was 79 %.
Conclusion:
According to our findings, most Italian general pediatricians do not seem to follow the recommendations of the 2009 NASPGHAN-ESPGHAN reflux guidelines and often prescribe PPIs despite a lack of efficacy for the symptoms being treated. We are well aware that the guidelines address the average situation and that the evaluation of individual patients may frequently reveal reasons for opening criteria for exceptions. Nevertheless, the over-diagnosis of gastroesophageal reflux disease (GERD) places undue burden on both families and national health system which has not been impacted by the publication of international guidelines.
... Gastroesophageal refl ux both impairs the quality of life and the negative impact is felt as a severe threat when severe symptoms are experienced (Knudsen et al. 1995;Vakil et al. 2006;Rey et al. 2007). An aspect of importance is that ultrasonography yields a non-invasive diagnostic measure that is readily applicable for pregnant women (Westra et al. 1990;Changchien and Hsu, 1996;Chen et al. 1997;Ramu et al. 2011). ...
The aim of the present study was to define some novel radiological clues that may aid in the ultrasonographic diagnosis of gastroesophageal reflux in pregnant women. A total of 84 pregnant women, consisting of 42 reflux patients and 42 controls were included in the study. Reflux and control groups were compared in terms of age and our novel ultrasonographic landmarks related to oesophageal structure. While the two groups did not differ in terms of age, they were significantly different from each other with respect to: single layer, single wall oesophageal thickness; double layer, double wall oesophageal thickness; oesophageal hiatal diameter; perioesophageal fat pad thickness; hypoechogenic single wall muscularis mucosa and lamina propria thickness. Owing to our newly defined radiological clues, ultrasonography may have a 'greater than expected' role in the diagnosis of gastroesophageal reflux in pregnant women. However, further studies must be performed to document the actual diagnostic potential of these radiological tips.
... According to the guidelines, US is not recommended as a test for GERD but can provide information not available through any other technology, allowing the exclusion of non-GER causes of symptoms, such as hypertrophic pyloric stenosis, hiatus hernia, and abdominal mass. When compared with the results of 24-hour esophageal pH testing, the sensitivity of color Doppler ultrasound, performed for 15 minutes postprandially, is approximately 95% with a specificity of only 11%, and there is no correlation between reflux frequency detected by US and reflux index detected by pH monitoring (13,14). To date, this is the first study to have assessed the use of US for GERD diagnosis in such an international setting. ...
To evaluate the implementation of the 2009 NASPGHAN-ESPGHAN guidelines, and to assess PPIs prescribing patterns among pediatricians from different European countries.
A randomly identified sample of general pediatricians distributed across 11 European countries was asked to complete a case report structured questionnaire investigating his approach to infants, children and adolescents with symptoms suggestive of gastroesophageal reflux.
A total of 567 European general pediatricians completed the study questionnaire. Only 1.8% of them showed complete adherence to the guidelines. Fourty-six percent of them reported that they diagnose GERD based on clinical symptoms irrespective of the age of the child; 39% prescribe PPIs in infants with unexplained crying and/or distressed behavior and 36% prescribe PPIs in infants with uncomplicated recurrent regurgitation and vomiting; 48% prescribed PPIs in children younger than 8-12 years of age with vomiting and heartburn, without specific testing; 45% discontinue PPI therapy abruptly rather than tapering the dose. The overall rate of pediatricians over-prescribing PPIs was 82%.
The overall results of our survey show that the majority of pediatricians are unaware of 2009 NASPGHAN-ESPGHAN guidelines and often prescribe PPIs despite a lack of efficacy for the symptoms being treated. The over diagnosis of GERD places undue burden on both families and national health systems which has not been impacted by the publication of international guidelines.
... CT scan can demonstrate the diaphragmatic discontinuity, intrathoracic herniation of abdominal contents, and waist-like constriction of mesenteric folds (the ''collar sign''). Displacement of the gastroesophageal junction or gastric fundus on the esophageal HHs can be clearly visualized on oral contrast-enhanced CT images, during Valsalva maneuver especially (3,6,8). ...
Diagnostic measures that can be used for sliding hiatal hernia are barium swallow radiography, endoscopy, manometry, and computed tomography. The aim of this study was to evaluate the diagnostic accuracy of transabdominal ultrasonography for sliding hiatal hernias.
This retrospective study was performed in the radiology department of a tertiary care center between May 2011 and May 2012. Twenty-one patients (10 females, 11 males) with sliding hiatal hernias and 41 controls (37 females, 4 males) were enrolled in this study. Esophageal hiatal diameters measured by ultrasonography and computerized tomography were compared. Correlation was tested via Pearson correlation analysis.
The average age of patients and controls were 58.6 and 40.1, respectively. There was a statistically significant difference between esophageal hiatal diameters measured via ultrasonography in patients (31.7 mm) and controls (11.6 mm) (P < .001). Similarly, esophageal hiatal diameters measured via computed tomography in patients (31.4 mm) was statistically significantly higher than controls (11.5 mm) (P < .001). The average body mass index of patients (28.3) was higher than that of control group (P = .015). Ultrasonographic measurements were correlated well with tomographic results (P = .000, r = 0.995).
Ultrasonography seems to be a valuable, safe, and practical alternative that avoids the side effects of contrast agents in the diagnosis of sliding hiatal hernias. Overall, we suggest that inclusion of ultrasound in the initial diagnostic steps for patients with sliding hiatal hernias may reduce the requirement for more expensive procedures.
