Abstract
ObjectivesSeveral clinical factors; overweight, male gender and increasing age, have been implicated as the etiology of hiatal hernia. Esophageal shortening due to acid perfusion in the lower esophagus has been suggested as the etiological mechanism. However, little is known about the correlation between gastric acidity and sliding hiatus hernia formation. This study examined whether increased gastric acid secretion is associated with an endoscopic diagnosis of hiatal hernia.MethodsA total of 286 consecutive asymptomatic patients (64 were diagnosed as having a hiatal hernia) who underwent upper gastrointestinal endoscopy were studied. Clinical findings including fasting gastric juice pH as an indicator of acid secretion, age, sex, body mass index, and Helicobacter pylori infection status determined by both Helicobacter pylori serology and pepsinogen status, were evaluated to identify predictors in subjects with hiatal hernia.ResultsMale gender, obesity with a body mass index >25, and fasting gastric juice pH were significantly different between subjects with and without hiatal hernia. The cut-off point of fasting gastric juice pH determined by receiver operating curve analysis was 2.1. Multivariate regression analyses using these variables, and age, which is known to be associated with hiatal hernia, revealed that increased gastric acid secretion with fasting gastric juice pH <2.1 (OR = 2.60, 95% CI: 1.38–4.90) was independently associated with hiatal hernia. Moreover, previously reported risk factors including male gender (OR = 2.32, 95% CI: 1.23–4.35), body mass index >25 (OR = 3.49, 95% CI: 1.77–6.91) and age >65 years (OR = 1.86, 95% CI: 1.00–3.45), were also significantly associated with hiatal hernia.ConclusionsThis study suggests that increased gastric acid secretion independently induces the development of hiatal hernia in humans. These results are in accordance with the previously reported hypothesis that high gastric acid itself induces hiatal hernia development.
Highlights
Hiatal hernia is a herniation of the gastric cardia through the esophageal hiatus of the diaphragm
Multivariate regression analyses using these variables, and age, which is known to be associated with hiatal hernia, revealed that increased gastric acid secretion with fasting gastric juice pH
This study suggests that increased gastric acid secretion independently induces the development of hiatal hernia in humans
Summary
Hiatal hernia is a herniation of the gastric cardia through the esophageal hiatus of the diaphragm. Two traditional etiologies of hiatal hernia have been suggested: decreased elasticity of ligamentous structures around the diaphragmatic hiatus due to increased age, and esophageal axial pressure strain through the diaphragm due to increased intragastric pressure induced mainly by obesity [5, 6]. Several investigators have reported that acid perfusion in the esophagus results in reflex contraction of the esophageal longitudinal smooth muscle and consequent esophageal shortening in both experimental animal studies and humans. A report from Japan by Iwakiri et al noted that the prevalence of hiatal hernia in patients with closed-type (low-grade) gastric mucosal atrophy was significantly higher than that of open-type (high-grade) gastric mucosal atrophy, suggesting that acid exposure to the esophagus induces hiatal hernia formation clinically [10]. It is possible that acid-induced esophageal shortening may result in formation of a vicious cycle, whereby the hiatal hernia exacerbates reflux, which in turn induces more esophageal shortening and the production of a larger hernia
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