Abstract
Sliding hiatal hernia is a frequently diagnosed condition, endoscopically defined as a more than 2 cm separation of the caudally displaced esophagogastric junction and diaphragmatic impression. Despite its frequency, there is little known about the validity of this definition. This video shows the most commonly used method to define sliding hiatal hernia, as well as certain pitfalls that can result in an under- or overdiagnosis of hiatal hernia. This article is part of an expert video encyclopedia.
Keywords
Video Related to this Article
Technique
Esophagogastroduodenoscopy.
Materials
- •Gastroscope: GIF-H180J; Olympus, Tokyo, Japan.
- •Gastroscope: EG-250WR5; Fujinon, Tokyo, Japan.
Background and Endoscopic Procedures
The anatomy around the esophagogastric junction is complex, especially because the anatomical positions of upper gastrointestinal structures change during swallowing, inspiration, and insufflation of air into the stomach.
1
Endoscopically, the esophagogastric junction can be defined as being at the proximal margin of the gastric mucosal folds, or as the squamocolumnar junction. The latter definition cannot be used in case of Barrett's esophagus, because in this condition, the native squamocolumnar junction has disappeared.The esophagogastric junction functions as a barrier to prevent reflux of gastric content to the esophagus. One of the components of this barrier is the lower esophageal sphincter; the other component is the sphincter-like function of the crural diaphragm.
1
Normally, the axial position of the squamocolumnar junction and lower esophageal sphincter is within or just slightly distal to the diaphragmatic hiatus and surrounded by the crural diaphragm.2
A sliding hiatal hernia is defined as a significant axial prolapse of a portion of the stomach through the diaphragmatic esophageal hiatus. Endoscopically, it is usually described as a more than 2-cm separation of the upward displaced esophagogastric junction and diaphragmatic impression. Using this endoscopic definition, sliding hiatus hernia is diagnosed in approximately a fifth of routine upper gastrointestinal endoscopies.
1
There is a clear relation between the gastro-esophageal reflux disease and sliding hiatal hernia. Approximately 75% of patients with reflux-esophagitis have a hiatal hernia, compared to approximately 10% of patients without esophagitis. Moreover, half the patients with hiatal hernia have esophagitis, whereas this is uncommon in patients without hiatal hernia.1
As barium swallow examinations are rarely performed nowadays and esophageal manometry is not widely available, the diagnosis of hiatal hernia usually solely relies on upper gastrointestinal endoscopy. Despite the prevalence of gastro-esophageal reflux disease and hiatal hernia, the diagnostic accuracy and interobserver variability of the endoscopic diagnosis of hiatal hernia have not been studied extensively. Easy as it seems, there are several important factors an endoscopist needs to be aware of before evaluating the presence of a hiatal hernia.
First, all endoscopic measurements of positions and length are determined using the hash marks on the endoscope, which are spaced 5 cm apart. This automatically implies a relative large error of measurement. Second, it is often quite difficult to establish the exact position of the esophagogastric junction. The distance of the proximal margin of the gastric mucosal folds to the incisors can significantly vary circumferentially.
3
Additionally, in case of Barrett's esophagus, the location of the squamocolumnar junction cannot be used as an indicator of the esophagogastric junction. The axial position of the diaphragmatic hiatus is also difficult to establish. It can vary circumferentially, and is additionally dependent on respiration and the amount of air in the stomach. The size of the hiatus can be estimated with the endoscope in retroversion, but again, this is dependent on respiration. All these potential sources of error make the endoscopic diagnosis of hiatal hernia difficult and harbor the risk of both under- as well as overdiagnosis.As stated before, hiatal hernia can only be diagnosed when there is a significant herniation of gastric cardia through the diaphragmatic hiatus. However, variations of the esophagogastric junction could predispose to gastroesophageal reflux, even without clear herniation being present. These variations can be described using the Hill classification, which relies on the endoscopic aspect of the gastroesophageal valve seen from a retroflexed position.
4
In grade I, which describes the normal appearance, prominent fold tissue closely approximates the endoscope at its entry point to the stomach. In grade II, the prominent fold is present, but there are occasional episodes of rapid opening and closing of the tissue around the endoscope. In grade III, there is barely a fold present, and there is no circular gripping of the endoscope shaft. There is, however, no herniation of gastric cardia through this persisting aperture. In grade IV, such herniation is present and squamous epithelium of the distal esophagus can be seen from the retroflexed endoscopic view.In conclusion, there is much uncertainty and room for error in the endoscopic diagnosis of hiatal hernia. Care should be taken in describing slight herniation as a cause of pathology. Clear endoscopic images of the esophagogastric junction from the antegrade and retrograde endoscopic views are important in documenting endoscopic findings.
Key Learning Points/Tips and Tricks
- •The esophagogastric junction can be defined as being at the proximal margin of the gastric mucosal folds, or as the squamocolumnar junction. The latter definition cannot be used in case of Barrett's esophagus.
- •Endoscopically, sliding hiatal hernia is usually defined as a more than 2-cm separation of the esophagogastric junction and diaphragmatic impression.
- •Recognition of the subjectivity and limited accuracy of endoscopic measurements, as well as the impact of mobility of the esophagogastric junction, is important to avoid over- or underdiagnosis of sliding hiatal hernia.
- •Abnormalities of the esophagogastric valve in the absence of clear herniation can be described using the Hill classification.
Complications and Risk Factors
- •The presence of Barrett's esophagus can be missed or underestimated when the esophagogastric junction is not identified correctly.
Alternatives
- •The presence of hiatal hernia can also be investigated using barium swallow radiography and manometry, although in general these methods suffer the same inaccuracies as endoscopy.
Scripted Voiceover
Tabled
1
| Time (min:sec) | Voiceover text |
|---|---|
| 00:00 | This is the esophagogastric junction of a 53-year-old man with reflux-esophagitis, LA-grade A. |
| 00:08 | The red arrow marks the diaphragmatic hiatus. |
| 00:12 | The blue arrow marks the squamocolumnar junction, which is at the same level as the proximal margin of the gastric mucosal folds. |
| 00:22 | The distance between these marks should be less than 2 cm. Otherwise a hiatal hernia is diagnosed. |
| 00:32 | As can be seen, the respiratory movements have a great impact on the esophagogastric junction, and interfere with endoscopic measurements. |
| 00:46 | With the endoscope in retroversion, the esophagogastric junction can be evaluated from an infradiaphragmatic viewpoint. |
| 00:56 | Again, the effect of respiration on the junctional anatomy can be appreciated. |
| 01:06 | The cardia is wide enough to allow a retroflexed view on the squamous epithelium of the esophagus. |
| 01:15 | The diaphragmatic impression is marked blue. |
| 01:22 | The squamocolumnar junction is marked with a red arrow. |
| 01:27 | There is no herniation of the cardia through the diaphragm, no apparent gastric flap valve, and the endoscope is not gripped by the tissue. This is consistent with Hill grade 3, which is associated with gastroesophageal reflux disease. |
| 01:54 | This the esophagus of a 62-year-old female with a very long segment Barrett's esophagus, extending up to 20 cm from the incisures. |
| 02:07 | In patients with Barrett's esophagus, the squamocolumnar junction cannot be used to identify the esophagogastric junction. |
| 02:15 | The rosette seen here is probably the location of the intrinsic lower esophageal sphincter. |
| 02:22 | Now, we enter the hiatal hernia and try to determine the length of the herniated part of the stomach, using the marks near the mouthpiece of the patient. |
| 02:42 | The tip of the endoscope is now near the proximal margin of the gastric folds. |
| 02:45 | The length of the hiatal hernia is estimated to be 4 cm, but again, this varies with respiratory movements. |
| 03:03 | Here, we ask the patient to breathe in deeply, resulting in raising and lowering of the diaphragm. |
| 03:36 | Now, we evaluate the esophagogastric junction from a retroflexed position. |
| 03:49 | In the distance we see the endoscope entering through the diaphragmatic aperture. |
| 03:54 | The point where the endoscope enters the cardia is marked with a red arrow. |
| 04:02 | The diaphragmatic aperture is marked blue. |
| 04:10 | Since we know the diameter of the endoscope, which is 8.5 mm in this case, we can estimate the diameter of the hiatal aperture is around 3.5 cm. |
| 04:30 | Using the 5-cm marks on the endoscope, we can estimate the length of the herniated part of the cardia is around 4 cm. |
| 04:40 | Since there is clearly over 2 cm distance between the diaphragmatic impression and the esophagogastric junction, a hiatal hernia can be diagnosed with certainty. |
References
- The Role of Hiatus Hernia in Gastro-oesophageal Reflux Disease.Eur. J. Gastroenterol. Hepatol. 2004; 16: 831-835
- Approaches to the Diagnosis and Grading of Hiatal Hernia.Best Pract. Res. Clin. Gastroenterol. 2008; 22: 601-616
- The Role of the Hiatus Hernia in Gastro-oesophageal Reflux Disease.Aliment. Pharmacol. Ther. 2004; 20: 719-732
- The Gastroesophageal Flap Valve: In Vitro and In Vivo Observations.Gastroint. Endosc. 2004; 44: 541-547
Article info
Publication history
Accepted:
September 29,
2012
Received in revised form:
September 25,
2012
Received:
August 30,
2012
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© 2013 Elsevier GmbH. Published by Elsevier Inc.
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