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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.
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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.