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 lower esophageal sphincter, hiatal hernia, delayed gastric emptying, or
increased intragastric or intra-abdominal pressure. In adults, the most common cause appears
to be transient relaxation of the lower esophageal sphincter with reflux esophagitis.
With mild or transient symptoms, a trial of medical therapy is usually instituted without any
imaging procedures being performed. If the symptoms are persistent or severe, endoscopy
with biopsy is usually performed. In patients with swallowing difficulties, a barium swallow
can demonstrate a mass or a stricture, which then requires endoscopic biopsy. A biopsy also is
indicated in immunocompromised patients and those with known Barretts esophagus. GERD
can be documented by use of an intraesophageal pH probe or less sensitive imaging or
nuclear medicine reflux studies.
The most common type of hiatal hernia is the sliding type, in which the gastroesophageal
junction and a portion of the fundus of the stomach slide upward into the thorax. Small hiatal
hernias can be identified by noting an indentation at the distal esophagus (Schatzkis ring), as
well as longitudinal gastric mucosa folds distal to the ring ( Fig. 624 ). Large hiatal hernias
can be identified by seeing the fundus of the stomach projecting up into the retrocardiac
space ( Fig. 625 ). Another type of hiatal hernia occurs more rarely. This is the
paraesophageal type, in which the fundus of the stomach slips up past the gastroesophageal
junction, which remains in the normal location. Large hiatal hernias can be seen on the chest
x-ray, even without the use of barium. The typical finding is an air/fluid level or soft tissue
mass located behind the heart but in front of the spine ( Fig. 626 ).
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 identified. The two keys to identification are
(1) a very sharp ringlike construction (called Schatzkis ring, which is seen between the two white
arrows); and (2) the normal longitudinal li nes of gastric mucosa (black arrow), which can be seen
projecting up above the hemidiaphragm

Large sliding-type hiatal hernia (HH). A large portion of the fundus of the stomach (St) has slipped up
through the hemidiaphragm into the retrocardiac region (arrows) and can easily be identified on an upper
gastrointestinal examination.

Esophageal reflux can sometimes be seen on an upper GI examination, but if it is not seen,
the patient may still be refluxing at other times and under other conditions. A more sensitive
imaging method uses nuclear medicine. A small amount of radioactive material is mixed with

orange juice, which the patient drinks. A computer region of interest is set up over the chest,
abdominal compression is applied, and the patient is monitored for about 1 hour. If the study
is positive, reflux occurs, but if it is negative, the same caveat applies. A more invasive 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 above the gastroesophageal junction.
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Hiatus hernia is often considered synonymous with GERD. There is, however, a poor
correlation between the presence of hiatus hernia and GERD or reflux esophagitis. One area
of controversy 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 (95%) is the sliding hiatus hernia, with the
GEJ displaced more than 1 cm above the hiatus. The esophageal hiatus is often abnormally
widened to 3 to 4 cm (Fig. 29.7). The upper limit of normal hiatal width is 15 mm, and this is
most easily measured by CT. The gastric fundus may be displaced above the diaphragm and
present as a retrocardiac mass on chest radiographs. The presence of an airfluid level in
the mass suggests the diagnosis. Small, 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 LES and the presence of pathologic gastroesophageal reflux
are the crucial factors in producing symptoms and causing complications. Much less common
is the paraesophageal hiatus hernia, in which the GEJ remains in its
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normal location while a portion of the stomach herniates above the diaphragm (Fig. 29.8).
The mixed or compound hiatal hernia is the most common type of paraesophageal hernia
(Fig. 29.9). The GEJ is displaced into the thorax with a large portion of the stomach, which is
usually abnormally rotated. Paraesophageal hernias, especially when large with most of the
stomach in the thorax, are at risk for volvulus, obstruction, and ischemia.

FIGURE 29.8. Sliding Hiatus hernia. CT demonstrates a 26mm gap between the crura (arrowheads) of the diaphragm. The normal esophageal hiatus
should not exceed 15 mm. The stomach (S) extends through the hiatus and is positioned both
above and below the diaphragm. The gastroesophageal junction was seen at a higher level in
the thorax.