the role of the hiatus hernia in gastro-oesophageal | Gastroesophageal Reflux Disease | Esophagus

Aliment Pharmacol Ther 2004; 20: 719–732.

doi: 10.1111/j.1365-2036.2004.02149.x

Review article: the role of the hiatus hernia in gastro-oesophageal reflux disease
C. GOR DON, J. Y. KAN G, P. J. NEILD & J. D. MAX WELL Department of Gastroenterology, St George’s Hospital, London, UK
Accepted for publication 26 June 2004

SUMMARY

A sliding hiatus hernia disrupts both the anatomy and physiology of the normal antireflux mechanism. It reduces lower oesophageal sphincter length and pressure, and impairs the augmenting effects of the diaphragmatic crus. It is associated with decreased oesophageal peristalsis, increases the cross-sectional area of the oesophago-gastric junction, and acts as a reservoir allowing reflux from the hernia sac into the oesophagus during swallowing. The overall effect is that of increased oesophageal acid exposure. The presence of a hiatus hernia is associated with symptoms of gastrooesophageal reflux, increased prevalence and severity of

reflux oesophagitis, as well as Barrett’s oesophagus and oesophageal adenocarcinoma. The efficacy of treatment with proton pump inhibitors is reduced. Our view on the significance of the sliding hiatus hernia in gastrooesophageal reflux disease has changed enormously in recent decades. It was initially thought that a hiatus hernia had to be present for reflux oesophagitis to occur. Subsequently, the hiatus hernia was considered an incidental finding of little consequence. We now appreciate that the hiatus hernia has major patho-physiological effects favouring gastro-oesophageal reflux and hence contributing to oesophageal mucosal injury, particularly in patients with severe gastro-oesophageal reflux disease.

INTRODUCTION

Winklestein first described gastro-oesophageal reflux disease (GERD) in 1935,1 and Allison2 highlighted the association between oesophagitis and hiatus hernia. For many years it was thought that a hiatus hernia had to be present for reflux to occur.3 In 1972, Cohen et al. drew attention to the role of a persistently hypotensive lower oesophageal sphincter (LOS) in patients with GERD.4 However, many patients with GERD were then found to have basal LOS pressure within the normal range.5 In 1982, Dodds et al.6 emphasized transient lower oesophageal sphincter relaxations (TLOSRs) not associated with swallowing and their role in the
Correspondence to: Dr J. Y. Kang, Department of Gastroenterology, St George’s Hospital, Blackshaw Road, London SW17 0QT, UK. E-mail: jykang@sghms.ac.uk Ó 2004 Blackwell Publishing Ltd

aetiology of GERD. Subsequent studies have shown that TLOSRs are in fact physiological,7, 8 and they underlie the majority of reflux events in healthy subjects.9 The pathogenesis of GERD is now recognized to be multifactorial, involving the LOS, diaphragmatic crus, oesophageal acid clearance, gastric acid secretion, gastric emptying and intra-abdominal pressure. But what of the hiatus hernia? The association between hiatus hernia and GERD has long been recognized.2, 10 Much work has been done recently to elucidate the effect of the hiatus hernia in the pathophysiology of GER, and we are now beginning to understand this complex relationship.11 The pendulum has swung back, and like flared trousers and other icons of the 1960s, the hiatus hernia is coming back into fashion. This review looks at how the hiatus hernia influences antireflux mechanisms, GERD and its complications in adults.
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with the sling fibres of the cardia.16 suggested that the phrenic ampulla is physiologically distinct from the oesophagus. OESOPHAGEAL ANATOMY AND PHYSIOLOGY IN NORMAL SUBJECTS a pressure of 6 mmHg or less is required for GER. and initiates swallowing.28. proposed that this functions as an extension of the abdomen into the mediastinum.30 The importance of the length of oesophagus within the hernia sac is seen in the autopsy study of 55 patients by Bombeck et al. The LOS is approximately 4 cm long.25 3 The distal portion (approximately 2 cm) of the oesophagus is thought to act as a valve. simultaneous fluoroscopic and manometric studies of the gastro-oesophageal junction (GOJ) by Lin et al.13.19.13 but reduces afterwards. 2 cm of which lies intra-abdominally. 14 and the gastric cardia tents through the diaphragmatic hiatus. It is a functional barrier with no anatomical landmarks. using keywords: hiatus hernia/gastro-oesophageal reflux disease/aetiology/prevalence/classification/ diagnosis/Barrett’s/proton pump inhibitors/oesophageal neoplasia/genetics/therapy. GORDON et al. and represents an intraluminal zone with a basal pressure greater than that of the stomach and oesophagus. The intrinsic muscles of the distal oesophagus and the proximal stomach. and this is thought to function as a valve.720 C.18 although there is a great deal of overlap and many patients with milder forms of GERD will have normal LOS pressure. which is formed by the fused endothoracic and endoabdominal fascia. and is analogous to a small reducing hiatus hernia. The distal end of the oesophagus is anchored to the diaphragm by the phreno-oesophageal ligament/membrane. forming a sac which contains part of the proximal stomach and distal oesophagus. In adults. form the intrinsic part of the LOS. the phrenoesophageal ligament is stretched in an orad direction.26. 29 In patients with hiatus hernia. provided a careful examination is performed. Studies on paediatric subjects were not included. and thus any increase in intra-abdominal pressure will be transmitted equally to the stomach and the intra-abdominal oesophagus. identified by a rise in pressure over the gastric baseline pressure as a pressure transducer is withdrawn from the stomach to the oesophagus. It has been suggested that . five of whom had no evidence of oesophagitis (and hence a competent cardia). and allows for transmission of intra-abdominal pressure to that portion of the LOS contained within the sac.23. This portion of the oesophagus is within the abdominal cavity.12 The longitudinal muscles of the oesophagus shorten during swallowing.21 and augments the oesophago-gastric junction (OGJ) when abrupt rises in intra-abdominal pressure occur. the reflux barrier is maintained. 4 The phrenoesophageal ligament inserts circumferentially into the oesophageal musculature close to the squamo-columnar junction.15 and is termed the phrenic ampulla. This is commonly seen on barium studies. and (iii) the LOS. This is augmented externally by a number of adjacent structures: 1 The crural diaphragm forms a sling around the GOJ and has been shown to have a sphincteric action distinct from that of the LOS.28 Eight patients had a hiatus hernia. METHODS A Medline search was performed. as long as the LOS maintains an intraluminal pressure increment greater than intragastric pressure. this zone has a pressure of approximately 20 mmHg (in one study with a range of 10–35 mmHg17). 27 Thus.22 2 The angle of His is the acute angle formed between the greater curvature of the stomach and the oesophagus. Aliment Pharmacol Ther 20.16 and contributes to the competence of the GOJ. it was regarded as part of the oesophagus and hence a physiological finding.16 The LOS is a manometrically distinct entity. from the 1966 to 2003 database and PreMedline. 20 It enhances the LOS pressure. 24 If the angle becomes less acute then reflux is more likely to occur. such as coughing or abdominal straining. (ii) body of the oesophagus – smooth muscle which propagates peristalsis under control of both the extrinsic (vagus) and intrinsic (Auerbach’s) plexus. limited to English language. However. 719–732 The oesophagus is a hollow muscular tube extending from the pharynx to the stomach. The phrenoesophageal membrane in these five patients Ó 2004 Blackwell Publishing Ltd. Other relevant publications known to the authors were also reviewed. DeMeester et al. Traditionally. It is composed of both striated and smooth muscle and functionally comprises three portions: (i) posterior cricoid portion – contains striated muscle under voluntary control.

as in peptic ulcer disease43. Tertiary contractions refer to non-peristaltic oesophageal activity. The GOJ remains fixed to the preaortic fascia and the arcuate ligament. even in patients with a hiatus hernia. they allow belching to occur. i. endoscopic and manometric . The remainder of this review will concentrate on the type I hiatus hernia. as in diabetes. While large hiatal herniae are easily identified in radiological.5. 46 Type I This is the commonest type.40 Delayed emptying of the proximal stomach may make reflux more likely due to a pressure backflow effect. with delayed emptying of the proximal stomach. Aliment Pharmacol Ther 20.37 This large volume of saliva contributes to the buffering of refluxed acid. e. In the three patients with oesophagitis (and hence an incompetent cardia). Transient lower oesophageal sphincter relaxations The TLOSRs are spontaneous relaxations to baseline of LOS pressure. the proportion of reflux episodes that can be ascribed to TLOSRs varies inversely with the severity of the disease. e. spleen. LOS pressure is reduced by cigarette smoking. peppermint. with laxity of the phrenoesophageal membrane. 719–732 The GOJ moves during swallowing in relation to the diaphragmatic crus. 44 and delayed gastric emptying. Oesophageal peristalsis can be primary (initiated by a swallow). In normal subjects.38 Although salivary flow in patients with GERD is similar to that Ó 2004 Blackwell Publishing Ltd. HIATUS HERNIA Hiatus hernia refers to the herniation of parts of the abdominal contents through the oesophageal hiatus of the diaphragm.35 alcohol36 and by some foods. and are distinct from swallow-induced LOS relaxations.32. Type II A type II hernia results from a localized defect in the phrenoesophageal membrane. or a hiatus hernia. 33 Over the whole spectrum of GERD. coordinated by the Auerbach’s plexus. There are three recognized types:45. 32 In patients with severe GERD other factors such as low basal LOS pressure. or secondary (initiated by distension of the oesophagus because of retained food or refluxed material). a low LOS pressure is an important determinant of GERD.5 cm above the GOJ. and induces primary peristalsis. 31. Type III hernias associated with a large defect can allow other organs to herniate.g. 42 Gastric outlet obstruction. LOS function and gastric emptying. This difference was significant and emphasizes the importance of an adequate length of intra-abdominal oesophagus in maintaining a competent antireflux mechanism. 8 They underlie the majority of reflux events in healthy individuals and patients with mild GERD. Type III Type III hernias are mixed types I and II.47 DIAGNOSIS Gastric acid is kept in the stomach by a combination of oesophageal motility. Many patients with GERD have an enhanced or prolonged postprandial fundic relaxation. The LOS relaxes completely during swallowing to allow passage of the ingested material. and is characterized by widening of the muscular hiatal aperture of the diaphragm.0. pancreas.44 can be associated with GERD. Coordinated peristaltic waves deliver the food boluses to the distal oesophagus from the mouth. with a sliding element to the type II hernia.34 PATHOPHYSIOLOGICAL MECHANISMS UNDERLYING GERD IN SUBJECTS WITHOUT HIATUS HERNIA in age-matched controls.g. with a pH of approximately 7. defective LOS function.6 cm above the GOJ. those with normal basal LOS pressure. and this has been proposed as a nonpharmacological treatment for GERD.e. In adults about 1000–1500 mL of saliva is secreted per day.REVIEW: HIATUS HERNIA AND GERD 721 inserted a mean of 3. the ligament inserted a mean of 0.41. as it accounts for about 90% of the hiatal hernias seen in clinical practice. This is achieved by voluntary (pharyngeal) and involuntary (oesophageal) muscle. As mentioned earlier. allowing some of the gastric cardia to herniate upwards.7.39 it can be doubled by chewing gum. are more important. and the gastric fundus forms the leading part of the herniation.

If a simple. the distal oesophagus and gastric cardia move cranially during swallowing and form the phrenic ampulla.48 and thus its presence above the diaphragmatic hiatus is used as a sign of a hiatus hernia. radiology is the only accurate method of measuring hiatus hernia size. our knowledge of the role of the hiatus hernia in GERD could be much advanced. There is no precise consensus regarding the differentiation of a phrenic ampulla. With a small hiatus hernia. When the probe is at the level of the diaphragm. from a hiatus hernia. which is physiological. In a normal subject. Therefore. Panzuto et al. as the probe lying in the stomach moves into the oesophagus as the diaphragm descends. deep inspiration causes a positive deflection followed by a negative deflection. standardized. the oesophagus shortens by up to 2 cm. Upper gastrointestinal endoscopy At upper GI endoscopy. only 20 met the radiological criteria for hiatus hernia. of 34 patients in whom hiatus hernias were diagnosed at upper GI endoscopy. which is pathological.50 They noted that upper GI endoscopy significantly underestimated the size of hiatus hernias compared with barium studies. Most authors agree that the lower oesophageal ring must be at least 1–2 cm above the level of the diaphragmatic hiatus to diagnose a hiatus hernia. the hiatus hernia can be caused by one or more of three mechanisms: (i) widening of the diaphragmatic hiatus. the distal border of the LOS is below the respiratory reversal point. 49 The current practice of diagnosing a hiatus hernia and measuring its size using the centimetre markings on the endoscope is inaccurate. the GOJ is recognized as the Z-line. In a normal subject. GORDON et al. endoscopic method of diagnosing a hiatus hernia and measuring its size could be developed. Oesophageal manometry When the manometry probe is in the stomach. returns the anatomy to its normal position. However. a deep inspiration is recorded as a positive deflection. Radiography On barium studies. The LOS is identified as a pressure rise above gastric baseline as the probe is pulled back from the stomach to the oesophagus – this falls back to baseline during swallows and periodically after eating (TLOSRs). There are few published data on the correlation between upper endoscopy and barium studies in the diagnosis of hiatus hernia. there is no standardized protocol in assessing and recording the reducibility of a hiatus hernia in between swallows or when getting upright from the supine position. In contrast. and hence part of the LOS appears intra-abdominal. an accurate measurement can be difficult because the diaphragm changes position with respiration.46.51 At present.49 It is also difficult to be certain that the tip of the endoscope is precisely at the Z-line or diaphragmatic crus while the distance from these landmarks to the incisors can vary circumferentially. 719–732 . When the probe is in the thoracic cavity a deep inspiration causes a negative deflection as thoracic pressure is lowered. and (iii) pushing up of the stomach by increased intra-abdominal pressure. It is only in large hernias that the LOS is proximal to the respiratory reversal point. as abdominal pressure rises.722 C.52 During a normal swallow. studied 21 patients with large hiatus hernias. upper GI endoscopy is now the standard tool for assessing upper GI symptoms. where the dark pink columnar stomach mucosa changes to the lighter pink squamous oesophageal mucosa above the visible stomach folds. the diagnosis of a small hiatus hernia is not well-standardized.46 AETIOLOGY Simplistically.45 although in practice the distinction can be quite arbitrary.46 Age-related ‘wear and tear’ of the phrenoesophageal ligament could loosen the Ó 2004 Blackwell Publishing Ltd. As discussed previously. especially the phrenoesophageal ligament. The elasticity of supporting structures. (ii) pulling up of the stomach by oesophageal shortening. studies. using both upper GI endoscopy and barium studies. Aliment Pharmacol Ther 20.49 Most authors consider a hiatus hernia to be present if diaphragmatic indentation is seen 2 cm or more distal to the Z-line and the top of the stomach mucosal folds. Small hiatus hernias were not included in this study. There is no standardization regarding the degree of air insufflation or which phase of respiration the measurement is made at. the GOJ is usually seen just above the diaphragmatic crus. In particular. This is called the respiratory reversal point. manometry is not a sensitive tool for the diagnosis of a hiatus hernia. the lower oesophageal mucosal ring demarcates the union of the oesophagus with the stomach.

analysed Ó 2004 Blackwell Publishing Ltd. like that of oesophagitis. although this did not reach statistical significance. impairing the sphincter function of the crural diaphragm. However. The development of hiatus hernia and crural diaphragmatic incompetence introduces further mechanisms of GER leading to exacerbation of oesophagitis and setting up a vicious cycle. PREVALENCE AND INCIDENCE OF HIATUS HERNIA It is commonly thought that obesity is a risk factor for reflux symptoms. 719–732 The frequency of hiatus hernia.53 Mittal46 proposed a unifying hypothesis relating GER and oesophagitis to the pathogenesis of hiatus hernia. Frequent TLOSRs with resultant acid reflux could be the initiating factor causing oesophagitis. but the nature of this association is unclear. no definite gender effect. However. the probability of hiatus hernia increasing with each level of obesity. Aliment Pharmacol Ther 20. or by a common relationship with hiatus hernia. Twenty-three had radiological evidence of a hiatal hernia. In a literature review by Pridie. This raises the ´ possibility of genetic inheritance.65–67 Prevalence data relating to the hiatus hernia are difficult to interpret.47 whether the association arises through the types of food obese people eat.63 Stein-Larson et al.55.60 38 members of a family pedigree across five generations were studied. In a retrospective case–control study of 1205 patients who underwent upper endoscopy. and as selection criteria for this procedure vary. which leads secondarily to oesophageal shortening through acid-induced contraction of the longitudinal muscles. diagnostic criteria for hiatus hernia vary between studies. a view shared by Barak et al. Is it a pure pressure effect? Or is it related to a lax hiatal orifice? It would be interesting to study the effect of weight loss on the size of a hiatus hernia. This may lead to subsequent fibrosis. Details such as age and body mass index are seldom presented. reflux symptoms and body size as part of a population-based. it was largely through an association with hiatus hernia. and in some reports are not even described.69 or no difference. There is therefore an association between obesity and hiatus hernia. it is unclear whether obesity in itself increases the risk for GERD.61 proposed that although obesity was a significant risk factor for oesophagitis. OBESITY AND HIATUS HERNIA the risk of reflux oesophagitis on the basis of their body mass index61 and showed that obesity is a significant risk factor for oesophagitis. or whether they merely reflect variability in patient selection and diagnostic criteria.54 A high prevalence of hiatus hernia of up to 80%55 amongst power athletes suggests a role for raised intraabdominal pressure. No individual with a hiatus hernia was born to unaffected parents. A hiatus hernia then results. 56 However. it is difficult to draw definite conclusions from these data. examined the relationship between hiatus hernia. it is uncertain if these differences are genuine.. Familial clusters of hiatus hernia have been des´ cribed. however. Wilson et al. and indeed weight loss forms part of the lifestyle advice given to patients with GERD. exacerbated by age-related loss of elasticity of the surrounding structures.68 female predominance.57–59 In a recent study by Carre et al.65–67 There is. Intraoesophageal acid perfusion causes proximal migration of the LOS. In one case direct maleto-male transmission was shown. They generally relate to patients attending for upper endoscopy rather than community subjects. since the frequency of hiatus hernia in the general population is still not clear. the extreme intraabdominal pressures seen in this setting (up to 365 mmHg amongst those who wear a lifting belt55) is far beyond that normally encountered in the normal subjects. because of genetic or lifestyle variations. While there is geographical variation in the prevalence of hiatus hernia.63 Wu et al.62 Logistic regression analysis of 385 dyspeptic patients in the UK and Singapore showed that body mass index was an independent risk factor for both hiatus hernia and reflux oesophagitis. increases with age. also described an association between obesity and the occurrence of both hiatus hernia and reflux oesophagitis in a prospective study of 1224 patients undergoing upper endoscopy. different series showing male predominance.16 and thus over time contribute to the formation of a hiatus hernia. Excessive body weight was also significantly associated with the presence of hiatus hernia. which Carre proposed 60 occurs in an autosomal dominant fashion. such data are not strictly comparable across series.64 A positive trend was found between increasing body size and hiatus hernia presence. which in turn enlarges the oesophageal hiatus.REVIEW: HIATUS HERNIA AND GERD 723 attachment of the GOJ to the diaphragmatic crus.70 the frequency of hiatus hernias found incidentally during barium studies . case–control study of the risk of upper GI cancers. Wilson et al. and thus is unlikely to be a major factor in the causation of hiatus hernia in the general population. Furthermore.

Most studies relate to symptomatic subjects undergoing investigation.005). more likely to be female and had a higher incidence of reflux oesophagitis or Barrett’s metaplasia compared with those who did not develop a hiatus hernia. and it was not stated if any of the patients with a hiatus hernia at the index upper endoscopy were found not to have a hiatus hernia at a subsequent upper endoscopy. One radiological study reported a 33% prevalence of hiatus hernia in asymptomatic individuals. the prevalence rose to between 11. the proportion with a hiatus hernia was 2. Hiatus hernia has been reported in about 11% of such individuals in one Korean series. and thus the results are difficult to interpret. For example. 78. an annual incidence of 19. a hiatus hernia alters the anatomy of the cardia and facilitates the ability of the gastric wall tension to pull open the LOS.8 and 2. who had a second procedure (for newly developed or recurrent symptoms) over a study period of up to 8 years. the portion of the LOS exposed to intra-abdominal pressure is shorter. 79 LOS pressure is reduced.51 Similarly. but reliable data are unavailable.78 Oesophageal peristalsis The presence of a large hiatus hernia is associated with decreased peristaltic amplitude in the distal Ó 2004 Blackwell Publishing Ltd. PHYSIOLOGICAL EFFECTS OF HIATUS HERNIA LOS function In a patient with a hiatus hernia. for abnormal oesophageal acid exposure.6% of 670 subjects (Norway). a practice which is now obsolete. in addition to a defective LOS. 17. A patient with a hypotensive LOS and a large hiatus hernia is more likely to develop GER during straining manoeuvres compared to a patient with a hypotensive sphincter alone. defined as a distance of more than 2 cm between the OGJ and the diaphragmatic indentation.77 However.66 Loffeld and Van der Putten67 calculated the incidence of hiatus hernia for a cohort of patients with a normal index upper endoscopy. However.8 and 29.5% had a hiatus hernia. Throughout the 1930s and 1940s.1% of 1010 patients in Korea.73 and 4. and may reflect the fact that the frequency of GERD is thought to be increasing in the East in recent years. In the Far East.70 The GERD is generally thought to be uncommon in the Far East. Of patients undergoing upper endoscopy. upper GI endoscopy is frequently performed as part of a routine medical check up.78 It has been proposed that in the presence of a structurally normal LOS. GORDON et al. Higher frequencies of hiatus hernia have been reported in Western populations. However. The frequency of hiatus hernia in asymptomatic individuals would be of great interest. Ninety of 353 patients developed a hiatus hernia.9%. in the 1950s and early 1960s. 2. 16.2% of 2044 subjects71 and 7% of 464 subjects72 in Taiwan.75 22% of 293 subjects (USA).10 and 14.30.68 In a recent Japanese series of 6010 individuals undergoing upper endoscopy between 1996 and 1998. for this study.724 C. varied widely depending on when the studies were performed.9% seems high. The incidence of hiatus hernia in this highly selected group of patients was 19.65 This prevalence is higher than that shown by other studies in Far Eastern populations. Aliment Pharmacol Ther 20.79 These changes in LOS pressure and function seem to be due to the spatial separation of the pressure components derived from the intrinsic LOS and compression of the oesophagus within the hiatal canal.15 but the protocol included the application of abdominal pressure. 719–732 . rather than community subjects or asymptomatic individuals.80 and this is proportional to the size of the hiatus hernia. Patients who developed hiatus hernia were older. A comparative study by a single endoscopist between English and Singaporean patients with dyspepsia found that the proportion of patients with hiatus hernia was 49% and 4% respectively (P < 0. the reported prevalence was between 0. The reproducibility of the endoscopist’s diagnosis of hiatus hernia was not assessed. the presence of a hiatus hernia is an independent risk factor.9% of 11 943 subjects in Singapore. the diagnostic criteria for hiatus hernia were not described.74 However. and the prevalence of hiatus hernia seems to follow this trend. these subjects represent a self-selected group who may not be comparable with community subjects.6%.9%.80 Impairment of the diaphragmatic sphincter A hiatus hernia compromises the diaphragmatic sphincter independently of its effects on the LOS.5% of 1000 subjects (Sweden)76 undergoing upper endoscopy were found to have a hiatus hernia. when abdominal pressure was routinely applied during barium examinations. most of whom were asymptomatic.

The cross-sectional area was greater in patients with a hiatus hernia and GERD than in patients with GERD but no hiatus hernia. compared with normal subjects and those with hiatus hernias <2 cm. Both these studies suggest that a hiatus hernia acts as a reservoir.88 Ó 2004 Blackwell Publishing Ltd. showed that patients with larger (>2 cm) hiatus hernias were more likely to have abnormal results on 24 h pH monitoring. or if it is secondary to oesophageal damage because of GER.83 were able to study the opening of the GOJ and to measure its cross-sectional area and compliance during low pressure distension. Van Herwaarden’s subjects were semiambulant. increasing hiatus hernia size was associated with greater oesophageal acid exposure. Oesophageal acid clearance In a study combining barium examinations with oesophageal pH studies. more prolonged episodes of reflux and longer acid clearance times. had small standardized meals and were studied over 24 h. thus contributing to the increased acid exposure time seen in these patients. The larger cross-sectional area could allow reflux of fluid rather than gas. patients with hiatus hernia did have more reflux associated with low LOS pressure. These contents could then reflux into the oesophagus when the LOS relaxed during swallowing. Massey argued that the presence of a hiatus hernia is more important than its size in its effects on GERD. patients with a hiatus hernia showed a biphasic response – an initial episode of acid reflux. Compliance was increased in GERD patients compared with controls.85 In the absence of a hiatus hernia. However.REVIEW: HIATUS HERNIA AND GERD 725 oesophagus. The conflicting conclusions reached by these two studies could be due to differences in study design. Pandalfino et al. Mittal et al. Cross-sectional area of the gastro-oesophageal junction Using a barostat filled with radioactive contrast. 719–732 . In 10 of the patients. The resultant TLOSR frequency was proportional to the size of the hiatus hernia. Sloan and Kahrilas studied asymptomatic volunteers and patients with symptomatic GERD who had hiatus hernias noted during upper endoscopy. gastric distension elicited a greater increase in the frequency of TLOSRs in patients with a hiatus hernia compared to those without. and this in turn was greater than that in normal subjects.85 proposed that gastric contents could be trapped in the hiatus hernia limited by the LOS proximally and the crural diaphragm distally.82 studied the effects of gastric distension (by gaseous infusion) on TLOSRs in GERD patients. from which acid can reflux during a swallow. and in 32% of swallows in the non-reducing group. However. the hiatus hernia was reducing while in the other 12 it was non-reducing. More work needs to be done to determine if TLOSRs are a significant cause of GER in the presence of a hiatus hernia. Ott et al. While the amount of reflux and frequency of TLOSRs at baseline were unaffected by the presence of a hiatus hernia. followed by restoration of pH towards normal.5 studied GERD patients with and without hiatus hernia. Aliment Pharmacol Ther 20. seen as a fall in pH.87 However. the frequency of TLOSRs and proportion associated with acid reflux was similar in the two groups. While those with a hiatus hernia had greater oesophageal acid exposure and more reflux episodes.78. Transient lower oesophageal sphincter relaxations What about the effect of a hiatus hernia on TLOSRs? Van Herwaarden et al. a single swallow resulted in restoration of a normal oesophageal pH. 79 This may impair the clearance of refluxed acid. Ten of the 22 patients had endoscopic oesophagitis. In a detailed pathophysiological study of nine controls and 38 patients with GERD.86 Complete oesophageal emptying without retrograde flow was seen in 86% of test swallows in controls. Kahrilas et al. with the stomach distended with 2 200 mL saline and 1800 mL air.82 performed their study in recumbent patients over 21 h. 66% of swallows in the reducing hiatus hernia group. Mittal et al. Using concurrent videofluoroscopy and manometry.81 It is uncertain whether this defective peristalsis is caused by the hiatus hernia. swallowassociated LOS relaxations and straining during periods with low LOS pressure. and possibly a higher volume of refluxate. Kahrilas et al. Simultaneous radionuclide studies showed that the initial drop in pH coincided with reflux from the hiatus hernia proximally.84 The increase in oesophageal acid exposure with hiatus hernia is not just due to increased frequency and volume of refluxate. instilled acid into the oesophagus of patients with and without hiatus hernia.

a hiatus hernia reduces LOS length and pressure. In a later study.51 the same authors considered these same subjects not to have hiatus hernias.75 Wright and Hurwitz10 Cronstedt et al. non-erosive disease.92 62% with GER symptoms at computer interview had a hiatus hernia at upper endoscopy. Patients without Number of Patients with oesophagitis (%) oesophagitis* (%) patients 64 32 13 68 63 84 72 6 3 2 11 8 13 9 UK/Singapore 383 Korea 1010 Singapore 11 943 Norway 1224 Norway 670 USA 293 Sweden 1000 Ó 2004 Blackwell Publishing Ltd.68 Kang et al. In summary. is associated with decreased oesophageal peristalsis. Oesophagitis and hiatus hernia The relationship between oesophagitis and hiatus hernias has been recognized as far back as 1951. is now the standard modality of investigating upper GI anatomy.89–91 recently drew attention to hiatus hernia which reduce when the patient is in the upright position. are between those for healthy volunteers and patients with irreducible hernias.86 The frequency of incomplete oesophageal emptying during swallows in these subjects was intermediate between healthy controls and those with irreducible hiatus hernias. CLINICAL EFFECTS OF HIATUS HERNIA Reflux symptoms and hiatus hernia ˚ In a study of 57 healthy subjects by Stal et al. They did not. which is always carried out in the supine position and in which the effects of swallowing are not assessed.93 investigated 930 successive patients who underwent endoscopy because of dyspepsia. even when reflux oesophagitis is not present at upper endoscopy. GORDON et al. although the reducibility or otherwise of hiatus hernias is potentially important in terms of pathophysiological considerations. Sloan and Kahrilas86 studied patients only in the supine position so the reducibility of hiatus hernias in the upright position was not assessed. Sloan and Kahrilas defined reducing hiatus hernias as those occurring only during mid-swallows. there is no uniformity in the assessment or reporting of the reducibility of hiatus hernias between swallows and in the upright position during barium studies. For this group of patients both the LOS pressure. patients with a hiatus hernia were significantly more likely to have heartburn and regurgitation compared to those without.73 Stein-Larson et al. Prevalence of hiatus hernia in patients with and without oesophagitis Frequency of hiatus hernia Location of study Kang and Ho66 Yeom et al. impairs the augmenting effect of the diaphragmatic sphincter. and the percentage time during which the lower oesophageal pH is <4. it can be seen that reflux symptoms are more common in subjects with a hiatus hernia than in those without. Even with exclusion of 131 patients with reflux oesophagitis.75. Furthermore endoscopy.. 88 Table 1 summarizes the results of various studies in which this relationship was analysed by univariate Table 1. In contrast. i.e.01).63 Berstad et al. and looked at both GERD and non-erosive reflux (NERD) patients. Thus. 719–732 .726 C. Peterson et al.76 * Statistically significant. In practice.2 Both the presence and size of the hiatus hernia are important. Thus. Aliment Pharmacol Ther 20. affects the opening characteristics of the OGJ and acts as a reservoir allowing GER during swallowing. The overall effect is that of increasing oesophageal acid exposure and decreasing oesophageal acid clearance. Subjects with GERD had predominantly non-erosive disease: only one quarter had oesophageal erythema or erosions. compared with only 14% of asymptomatic subjects (P < 0. Reducibility of hiatus hernia Mattioli et al. They suggested that hiatus hernias that reduce in the upright position represent a stage in the development of fixed hiatus hernias. report on the effect of swallowing on the reducibility of hiatus hernias. however. its clinical effects cannot be studied easily. but reducing between swallows.

Using multivariate analysis. and identified seven in whom complete regression of the Barrett’s occurred. 72% of patients with short segment (<2 cm) Barrett’s oesophagus. case–control study of patients with oesophageal adenocarcinoma (n ¼ 222). Barrett’s oesophagus and hiatus hernia Barrett’s oesophagus is associated with male sex.87 although the effect of presence or absence of a hiatus hernia was not analysed. 2170 patients with no GERD. Chow et al.94 Jones et al.100 In a population-based. both hiatus hernia and reflux symptoms emerged as significant risk factors. In a study of 229 patients with Barrett’s oesophagus and 229 patients with non-erosive GERD. although an association was demonstrable on univariate analysis. These studies included patients who had an upper GI endoscopy done for a variety of indications. and showed that the presence of a hiatus hernia doubled the risk of oesophageal carcinoma. prospectively followed up 99 patients over a period of 24–106 months. Pathophysiological effects of a hiatus hernia Decrease in intra-abdominal length of the lower oesophageal sphincter (LOS) Decreased LOS pressure Impairment of the diaphragmatic sphincter Impairment of oesophageal peristalsis Increased cross-sectional area of the gastro-oesophageal junction (GOJ) Decreased oesophageal acid clearance Increased oesophageal acid exposure associated with a hiatus hernia. 75.66 The association between hiatus hernia and reflux oesophagitis is significant across different countries. and 1189 patients with Barrett’s oesophagus but no dysplasia. the presence of Barrett’s oesophagus was strongly Ó 2004 Blackwell Publishing Ltd. Stepwise logistic regression analysis showed that only the absence of a hiatus hernia and length of Barrett’s <6 cm were significantly and independently predictive of complete regression of the Barrett’s segment. those with Barrett’s oesophagus had wider hiatal orifices. acid clearance time and oesophagitis severity. Factors contributing to the antireflux mechanism in normal subjects Lower oesophageal sphincter (LOS) Crural diaphragm Angle of His Intra-abdominal portion of the LOS Phrenoesophageal ligament Oesophageal peristalsis Saliva 727 Table 3. Aliment Pharmacol Ther 20. demonstrated that the presence of a hiatus hernia was a more important predictor of reflux oesophagitis than LOS pressure. excess alcohol. 73. 63.96 Cameron looked at the prevalence and size of hiatus hernia in Barrett’s oesophagus.99 but few studies specifically examined the relationship between hiatus hernia and oesophageal carcinoma. sixfold in those with a hiatus hernia but no reflux symptoms. cigarette smoking and frequent reflux episodes. Logistic regression analysis showed the risk of high-grade dysplasia or esophageal adenocarcinoma to be proportional to the size of hiatus hernia and length of Barrett’s oesophagus. 719–732 There is an established association between GERD and oesophageal adenocarcinoma. Sontag et al. The risk was increased threefold in those with reflux symptoms but no hiatus hernia. showed that increases in hiatal hernia size were significantly correlated with total oesophageal acid-exposure. older age. performed a medical record based case–control study of 196 patients with oesophageal adenocarcinoma and 196 controls. reviewed 131 patients with high-grade dysplasia or oesophageal adenocarcinoma. Weston et al. In a third study by Cadiot et al. and longer hiatal hernias compared to patients without Barrett’s oesophagus. Among patients with hiatus hernias. irrespective of the background prevalence of this condition. and 29% of controls with no oesophagitis..95 the relationship between hiatus hernia and reflux oesophagitis was not statistically significant on multivariate analysis. and excess smoking and alcohol.10. 68. dysphagia and previously documented oesophagitis. 71% of patients with oesophagitis. Patients with high-grade dysplasia or oesophageal adenocarcinoma shared many characteristics with .97 A hiatus hernia was found in 96% of patients with classical Barrett’s oesophagus.98 Oesophageal adenocarcinoma and hiatus hernia analysis. 76 or for dyspepsia only. There was also a cumulative increase in risk with a history of reflux.REVIEW: HIATUS HERNIA AND GERD Table 2.64 Avidan et al. and eightfold in those with both reflux symptoms and a hiatus hernia. more reflux episodes.

106 We now know that the aetiology of GERD is multifactorial.105 and it may be that this residual acid refluxes more easily in the presence of a hiatus hernia. (ii) reconstruction of the diaphragmatic hiatus (with reduction of a hiatus hernia if present) and (iii) reinforcement of the LOS by fundoplication. 100% respectively). The two groups differed only in the presence of hiatal hernia (28% vs. However.106 During surgery the oesophagus is mobilized in the thorax so that it can be brought down sufficiently to restore the intra-abdominal portion. Acid suppression treatment and hiatus hernia Frazzoni et al.108 However. (ii) bulking techniques in which inert substances are injected into the lower oesophagus.103 Said et al. whether open or laparoscopic. 113 Both the reconstruction of the oesophageal hiatus and oesophageal lengthening can be achieved laparoscopically. early surgery was designed only to treat the hernia itself and was often ineffective for reflux oesophagitis. such as older age.102 Stepwise logistic regression analysis showed that progression to high-grade dysplasia and oesophageal adenocarcinoma were significantly and independently associated with hiatal hernia size.107. This could be due to the promoting effect of hiatus hernia on GER. A 30 mg dose of lansoprazole normalized oesophageal acid exposure in 70% of subjects.101 Weston et al.116 These include (i) endoscopic plicators which place sutures around the LOS. This reduces tension on the repair.104 Both these studies suggest that a hiatus hernia affects the ability of acid suppressing medication to normalize intraoesophageal pH. if left untreated. surgery is recommended for para-oesophageal hernias because.107 Antireflux surgery is indicated in patients affected by severe GERD who are (i) not compliant with long-term medical therapy. hiatal hernia size was not studied. male gender and white ethnicity.97 and reconstruction of the diaphragmatic hiatus is an integral part of antireflux surgery. 719–732 . Ó 2004 Blackwell Publishing Ltd. none of these techniques correct the anatomical abnormality.114 While the presence of a large hiatus hernia is associated with severe GERD symptoms.728 C. In contrast. To date subjects with hiatus hernia have not been included in the case series that have been published. Thus. approximately 33% will suffer complications such as intrathoracic incarceration of the stomach. Both the presence and size of a hiatus hernia were significantly associated with early recurrence on multivariate analysis. bleeding. who had been referred for upper GI endoscopy. a sliding hiatus hernia per se is not an indication for surgery. However. and an ideal operation. dysplasia at diagnosis and the length of the Barrett’s segment.107. it was thought that a hiatus hernia was the only causative factor leading to GERD. It has been shown that on standard doses of PPIs. The association between hiatus hernia. GORDON et al. (ii) who require high doses of drugs and (iii) who wish to avoid lifetime medical treatment. 112 but the presence of a large hiatus hernia might influence the surgeon to consider an open operation. in the context of a large or irreducible hiatus hernia. and reduces the risk of late failure. and not necessarily by the presence of the hiatus hernia per se. and thus are unlikely to be effective in patients who have significant hiatus hernias. and (iii) the STRETTA procedure in which radiofrequency energy is delivered to the LOS and gastric cardia. studied lower oesophageal pH in 50 patients with complications or atypical manifestations of GERD. prospectively followed up 108 patients with Barrett’s oesophagus. should address all the various aspects. nocturnal acid breakthrough commonly occurs. Aliment Pharmacol Ther 20.107 The operation most commonly used today is a modification of the operation described by Nissen in 1956. examined predictors of early recurrence of peptic oesophageal strictures after initial dilatation in 67 patients over a 1-year period.106 including (i) restoration of the intra-abdominal oesophagus. and Barrett’s oesophagus and oesophageal adenocarcinoma is consistent with a promoting effect of the hiatus hernia on GERD. there may be a short oesophagus despite adequate mobilization. Surgical and endoscopic therapy for GERD in the presence of hiatus hernia In the infancy of antireflux surgery.108–111 Oesophageal lengthening (Collis gastroplasty) combined with fundoplication can be performed during laparoscopic112 surgery.107 A large hiatus may be seen in patients with a large hiatus hernia. but may require an open operation. strangulation or perforation115 A number of novel endoscopic techniques have recently been described for the treatment of GERD. other forms of severe GERD. Continued acid suppression was used in 94% of patients. erosive oesophagitis and poorer response to treatment. whereas a 60 mg daily dose was necessary in the remainder.

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