High-Resolution Manometry for Assessing Hiatal Hernia in a Patient With Severe Reflux Esophagitis

Abstract

A 58 year-old man visited the hospital complaining heartburn, acid regurgitation and dysphagia, especially in the postprandial period and in the supine position. Los Angeles grade C reflux esophagitis and sliding hiatal hernia (HH) were identified from upper gastrointestinal endoscopy (Fig. 1). Barium esophagogram also showed reducible sliding hiatal hernia and normal barium transit to the stomach (Fig. 2). He underwent high-resolution manometry (HRM; version 2.1, Manoscan, Sierra Scientific Instruments Inc, Los Angeles, CA, USA) to evaluate the other causes of dysphagia. Figure 3 shows the HRM findings. The HRM diagnosis was intermittent hypotensive peristalsis. Mean distal esophageal amplitudes was 29.3 mmHg, the intergrated relaxation pressure was 9 mmHg and intrabolus pressure was 2 mmHg. During inspiration, HRM plot showed minimal separation of lower esophageal sphincter (LES) and crural diaphragm (CD), making double peak high pressure zone which is the typical finding of HH. Figure 1 The retroflexed endoscopic view shows sliding hiatal hernia. The gastroesophageal area is stayed open and squamous epithelium of distal esophagus is seen. Figure 2 Esophagogram also shows reducible sliding hiatal hernia. Figure 3 (A) A swallow shows hypotensive contraction. Two arrows point 2 high pressure zone. (B) During inspiration, the separation between the crural diaphragm and the lower esophageal sphincter (LES) was augmented making double pressure peak at esophagogastric ... HH presents with widening of the diaphragmatic hiatus and axial displacement between the LES and CD of sufficient magnitude that a pouch of stomach is sandwiched between two.1 Using HRM with pressure topography, the LES and CD elements of the esophagogastric junction (EGJ) can be selectively localized and their contractility quantified. HRM examples of EGJ pressure morphology subtypes are primarily distinguished by the extent of LES-CD separation.2 Type I HH is characterized by complete overlap of the CD and LES with a single pressure peak in the spatial pressure variation plots during both inspiration and expiration, which means normal finding. Type II HH is characterized by minimal, 1-2 cm LES-CD separation presenting a double peaked spatial pressure variation plot. Type III HH with greater than 2 cm separation is an overt hiatal hernia, a frequent finding in patients with gastroesophageal reflux disease whereas it is rarely found in asymptomatic controls or functional heartburn.2 Comprehensive evaluation on EGJ morphology or impaired EGJ components is possible by using HRM. This case is a patient with severe reflux esophagitis combined with low grade disruption of the EGJ (type II HH). There is quantifiable separation between the CD and the LES, but the magnitude of this separation is insufficient to constitute a overt sliding hernia. HRM is the only method capable of reliably detecting this condition, the intermediate stage between normal and overt sliding hiatus hernia.1