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ologyHiatal Hernia and Gastroesophageal Reflux Disease 

A large number of people suffer from “heartburn” or dysphagia as a result of reflux of gastric

contents into the esophagus. This may occur because of esophageal motility problems,

incompetence of the loer esophageal sphincter, hiatal hernia, delayed gastric emptying, or

increased intragastric or intra!abdominal pressure. "n adults, the most common cause appearsto be transient relaxation of the loer esophageal sphincter ith reflux esophagitis.

#ith mild or transient symptoms, a trial of medical therapy is usually instituted ithout any

imaging procedures being performed. "f the symptoms are persistent or se$ere, endoscopy

ith biopsy is usually performed. "n patients ith salloing difficulties, a barium sallo

can demonstrate a mass or a stricture, hich then re%uires endoscopic biopsy. A biopsy also is

indicated in immunocompromised patients and those ith &non 'arrett(s esophagus. G)RD

can be documented by use of an intraesophageal pH probe or less sensiti$e imaging or

nuclear medicine reflux studies.

The most common type of hiatal hernia is the sliding type, in hich the gastroesophageal *unction and a portion of the fundus of the stomach slide upard into the thorax. +mall hiatal

hernias can be identified by noting an indentation at the distal esophagus +chat-&i(s ring, as

ell as longitudinal gastric mucosa folds distal to the ring /ig. 0123 . 4arge hiatal hernias

can be identified by seeing the fundus of the stomach pro*ecting up into the retrocardiac

space /ig. 0125 . Another type of hiatal hernia occurs more rarely. This is the

 paraesophageal type, in hich the fundus of the stomach slips up past the gastroesophageal

 *unction, hich remains in the normal location. 4arge hiatal hernias can be seen on the chest

x!ray, e$en ithout the use of barium. The typical finding is an air6fluid le$el or soft tissue

mass located behind the heart but in front of the spine /ig. 0120 .

Small sliding-type hiatal hernia. When a small portion of the fundus of the stomach slips up through

the hemidiaphragm, a small hiatal hernia (HH) can be identied. The two eys to identication are

(!) a "ery sharp ringlie construction (called Schat#i$s ring, which is seen between the two white

arrows)% and (&) the normal longitudinal li nes of gastric mucosa (blac arrow), which can be seen

pro'ecting up abo"e the hemidiaphragm

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arge sliding-type hiatal hernia (HH). large portion of the fundus of the stomach (St) has slipped upthrough the hemidiaphragm into the retrocardiac region (arrows) and can easily be identied on an uppergastrointestinal e*amination.

)sophageal reflux can sometimes be seen on an upper G" examination, but if it is not seen,

the patient may still be refluxing at other times and under other conditions. A more sensiti$eimaging method uses nuclear medicine. A small amount of radioacti$e material is mixed ith

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orange *uice, hich the patient drin&s. A computer region of interest is set up o$er the chest,

abdominal compression is applied, and the patient is monitored for about 7 hour. "f the study

is positi$e, reflux occurs, but if it is negati$e, the same ca$eat applies. A more in$asi$e but

more accurate method used by gastroenterologists is to put a pH probe on the end of a tube

and station this for some time abo$e the gastroesophageal *unction.

)mail to 8olleague 9rint :ersion 

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Hiatus hernia is often considered synonymous ith G)RD. There is, hoe$er, a poor

correlation beteen the presence of hiatus hernia and G)RD or reflux esophagitis. ;ne area

of contro$ersy is the definition of hiatus hernia and the criteria used for diagnosis. The

simplest definition is protrusion of any portion of the stomach into the thorax. Three types of

hiatal hernia are described 5. The most common <5= is the sliding hiatus hernia, ith the

G)> displaced more than 7 cm abo$e the hiatus. The esophageal hiatus is often abnormallyidened to ? to 3 cm /ig. 2<.@. The upper limit of normal hiatal idth is 75 mm, and this is

most easily measured by 8T. The gastric fundus may be displaced abo$e the diaphragm and

 present as a retrocardiac mass on chest radiographs. The presence of an airB“fluid le$el in

the mass suggests the diagnosis. +mall, sliding hiatus hernias commonly reduce in the upright

 position. The mere presence of a sliding hiatus hernia is of limited clinical significance in

most cases. The function of the 4)+ and the presence of pathologic gastroesophageal reflux

are the crucial factors in producing symptoms and causing complications. Cuch less common

is the paraesophageal hiatus hernia, in hich the G)> remains in its

9.E5

normal location hile a portion of the stomach herniates abo$e the diaphragm /ig. 2<..The mixed or compound hiatal hernia is the most common type of paraesophageal hernia 

/ig. 2<.<. The G)> is displaced into the thorax ith a large portion of the stomach, hich is

usually abnormally rotated. 9araesophageal hernias, especially hen large ith most of the

stomach in the thorax, are at ris& for $ol$ulus, obstruction, and ischemia.

/"GFR) 2<.. +liding Hiatus hernia. 8T demonstrates a 20!

mm gap beteen the crura arroheads of the diaphragm. The normal esophageal hiatus

should not exceed 75 mm. The stomach + extends through the hiatus and is positioned both

abo$e and belo the diaphragm. The gastroesophageal *unction as seen at a higher le$el in

the thorax.