Hiatal Hernia Workup
- Author: Waqar A Qureshi, MD; Chief Editor: Julian Katz, MD more...
The typical reasons for evaluation are symptoms of GERD or a chest radiograph suggesting a paraesophageal hernia.
Barium upper gastrointestinal series
Although a chest radiograph may reveal a large hiatal hernia (see the first image below), and many incidentally diagnosed hiatal hernias are discovered in this manner, a barium study of the esophagus helps establish the diagnosis with greater accuracy (see the second image below).
Typical findings include an outpouching of barium at the lower end of the esophagus, a wide hiatus through which gastric folds are seen in continuum with those in the stomach, and, occasionally, free reflux of barium.
A barium study helps distinguish a sliding from a paraesophageal hernia (see the images below).
In rare cases, the entire stomach may herniate into the chest (see the image below).
The stomach may then undergo volvulus (see the image below) and subsequent incarceration and strangulation.
Hiatal hernia is diagnosed easily using upper gastrointestinal endoscopy.
The diagnosis of a hiatal hernia actually is incidental, and endoscopy is used to diagnose complications such as erosive esophagitis, ulcers in the hiatal hernia, Barrett esophagus, or tumor.
A hiatal hernia is confirmed when the endoscope is about to enter the stomach or on retrograde view once inside the stomach (see the image below). If any doubt remains, the patient may be asked to sniff through the nose, which causes the diaphragmatic crura to approximate, seen as a pinch, closing the lumen.
Endoscopy also permits biopsy of any abnormal or suspicious area.
Traditionally, esophageal manometry has had a low sensitivity for diagnosing hiatal hernia, as compared to endoscopy, and was therefore not appropriate in helping to establish a diagnosis.
More recent studies with esophageal high-resolution manometry (HRM) appear to be more accurate for detecting hiatal hernias. In one study that evaluated the HRM recordings, endoscopy reports, and barium esophagograms of 90 patients, HRM had a 92% sensitivity and 95% specificity for identifying hiatal hernias compared with a 73% sensitivity each for endoscopy and radiography.
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