Hiatal Hernia Patients Research Articles

Reflux esophagitis and its relationship to hiatal hernia.

We performed this study to evaluate the prevalence of reflux esophagitis and/or hiatal hernia in patients referred to a medical center and to examine the relationship between endoscopic reflux esophagitis and hiatal hernia. The study was carried out in 1,010 patients referred to Yong Dong Severance Hospital for upper gastrointestinal endoscopy because of symptoms related to the gastrointestinal tract from September 1994 to March 1996. The presence of hiatal hernia was defined as a circular extension of the gastric mucosa of 2 cm or more above the diaphragmatic hiatus. Reflux esophagitis was found in 5.3% of patients, hiatal hernia in 4.1%, duodenal ulcer in 7.2% and gastric ulcer in 8.2%. The prevalence rates of reflux esophagitis and hiatal hernia in males were significantly higher than those in females. Thirty-two percent of patients with reflux esophagitis had hiatal hernia. In patients without reflux esophagitis, hiatal hernia was found in only 2.5% (p<0.01). There was no significant association between the presence of hiatal hernia and the degree of esophagitis on endoscopy. Duodenal ulcer was the second most common endoscopic abnormality found in patients with reflux esophagitis. The prevalence rate of reflux esophagitis and/or hiatal hernia at a medical center is relatively low compared to peptic ulcer disease and other reports from the Western countries. Our study confirms the close association between reflux esophagitis and hiatal hernia.

Impact of fundoplication on bolus transit across esophagogastric junction.

This study analyzed the effect of fundoplication on the mechanics of liquid and solid bolus transit across the esophagogastric junction (EGJ). The squamocolumnar junction was endoscopically clipped in seven controls, seven hiatal hernia patients, and seven patients after laparoscopic Nissen fundoplication. Concurrent manometry and fluoroscopy were done during swallows of liquid barium and a 13-mm-diameter marshmallow. The EGJ opening, pressure gradients, transit efficacy, and axial motion were measured. The axial motion of the EGJ was reduced in the fundoplication and hiatal hernia patients. The opening dimensions at the squamocolumnar junction were similar among groups, but in each case the constriction limiting flow to the stomach was at the hiatus and this was substantially narrowed with fundoplication. As a result, liquid intrabolus pressure was increased and marshmallow transit frequently required multiple swallows. We conclude that fundoplication limits the axial mobility of the EGJ and leads to a restricted hiatal opening. These alterations decrease the efficacy of solid and liquid transit into the stomach and are potential causes of dysphagia in this population.

Pressure morphology of the gastroesophageal junction after fundoplication: How normal is it

Though effective in resolving esophagitis, fundoplication (FP) can impair belching, a venting mechanism that requires both a relaxed sphincter an d that intragastric pressure exceed extrasphincteric pressure. To better understand this limitation, we compared gastroesophageal junction (GEJ) pressure morphology after FP to that of normal volunteers (N1) and hiatal hernia (HH) patients. Methods: Metal clips were placed endoscopically to mark the intragastric margin of the GEJ and squamocolumnar junction (SCJ) in 7 Nls, 7 HH patients, and 7 patients after FP. GEJ pressure (0=atmospheric) referenced to the clips and hiatus was measured during concurrent videofluoroscopy and mechanized pull through of an 8-lumen manometer with radiopaque side holes at the same axial level but 45 ° apart radially. Subdiaphragmatic length (SDL) of the GEJ (shaded area in figure) was that distal to the hiatal canal, as localized in HH patients. Pull throughs were done during endexpiration, deep inspiration, and abdominal compression (AC) with a binder inflated to 100 mmHg. Results: Axial position of the SCJ was restored post-FP, but GEJ pressure morphology of each group was distinct (Figure & Table, All data mean -+ SE).

Incidence of Zenker's Diverticulum With a Hiatal Hernia

Linda Gage-White, MD, and Brian F. McCabe, MD, reported the experience of the University of Iowa Hospitals (Iowa City) with patients with concomitant occurrence of Zenker's diverticulum and hiatal hernia. Their retrospective review, which spanned a 40-year period, was presented at the Middle Section meeting of the Triological Society, Ann Arbor, Mich. Their research identified 104 patients who were noted to have both of these esophageal abnormalities. Male and female patients were equally affected in their study. The authors were able to identify an increased incidence of hiatal hernia in patients with Zenker's diverticulum, when compared with a control group of patients who underwent a barium swallow as part of a workup for head and neck malignancy. In the control group, the incidence of finding coincidental Zenker's diverticulum and hiatal hernia was 51%. Hiatal hernia was present in 38.5% of the patients with Zenker's diverticulum. The mechanism to explain this

Preoperative and postoperative levels of plasma protein and amino acid in esophageal and lung cancer patients.

The metabolic changes following thoracic surgery in three groups of patients (esophageal cancer, lung cancer, and hiatus hernia) have been studied. Before operation patients with esophageal cancer, but not those with lung cancer, had significantly lower plasma total protein and albumin than patients with hiatus hernia. After surgery plasma albumin and total protein fell in both esophageal cancer and hiatus hernia patients, a development attributed to poor nutrition and restricted calorie diet in these two groups of patients respectively. With the exception of alanine and arginine in lung cancer patients, and free tryptophan in lung and esophageal cancer patients, the preoperative concentrations of all plasma amino acids were similar in both groups of cancer patients and in those with hiatus hernia. After operation the concentrations of glutamine, total tryptophan, alanine, glycine, and arginine fell sharply, whereas those of phenylalanine, lysine, valine, and leucine were slightly or not at all affected by surgery. The immediate postoperative fall of plasma free amino acids is thought to be due to the increased rate of gluconeogenesis. The rise of free fraction of plasma tryptophan after surgery is related to the raised level of plasma free fatty acids and increased secretions of catecholamines, which is believed to follow surgery.

Incidence of Zenker's diverticulum with hiatus hernia.

The concomitant occurrence of Zenker's diverticulum and hiatus hernia in several patients prompted an investigation to determine whether there is a statistically significant increased incidence of hiatus hernia in patients with Zenker's diverticulum. Radiologic reports contained in 104 charts of patients from the University of Iowa with a diagnosis of Zenker's diverticulum were analyzed retrospectively for the presence of hiatus hernia. Radiologic reports contained in charts of a control group of patients, who had a barium swallow for work-up of a head and neck malignancy, were also analyzed. The control group had a 16% incidence of hiatus hernia, which was consistent with published data. The Zenker's diverticulum group had a 39% incidence of hiatus hernia, a statistically significant increase over the control group. The pathophysiology linking these conditions and the clinical implications of their relationship are discussed.

Gastroesophageal Reflux and Ascorbic Acid Insufficiency

The incidental discovery of scurvy in a patient with a symptomatic hiatal hernia has led to the identification of 9 other individuals with chemically proved vitamin C deficiency secondary to an expressed aversion to “acid” food in any form. These patients were screened with capillary fragility tests and serum ascorbic acid determinations from approximately 200 hiatal hernia and reflux patients. With resumption of a normal vitamin C intake, scattered deficiency symptoms disappeared and both capillary fragility tests and serum ascorbic acid levels returned toward normal. There were no wound healing problems.

Effect of perfusion of bile salts solutions into the oesophagus of hiatal hernia patients and controls.

Tests of the response to perfusion of the oesophagus were made in 54 patients divided into three groups. Group I consisted of patients with symptomatic hiatal hernia, group II hiatal hernia patients with peptic stricture, and group III normal individuals. Each individual oesophagus was perfused at a rate of 45-65 drops per minute over 25 minutes with six solutions: normal saline, N/10 HCl, taurine conjugates of bile salts in normal saline, taurine conjugates of bile salts in N/10 HCl, glycine conjugates of bile salts in normal saline, and taurine and glycine conjugates in a ratio of 1 to 2 in normal saline. It was found that acidified taurine solutions were more irritating than acid alone. With a 2mM/l solution of taurine in acid, symptoms are produced even in controls. With a 1 mM/l solution of the same conjugates, the majority of normal people feel slight heartburn or nothing, and therefore perfusion into the oesophagus of such a solution could be used as a test for oesophagitis.

Effects of posture in hiatus hernia as studied by oesophageal pH measurement.

The use of postural restriction in the treatment of patients with hiatus hernia has been analysed using continuous oesophageal pH measurements. It appears that it is not effective in the prevention of reflux of acid. The percentage of the time during which oesophageal pH remains below 5 is not significantly different when comparison is made during periods of sitting and lying. The frequency of reflux episodes is actually greater in the sitting position, but the duration of each reflux episode is significantly shorter than when lying. It is suggested that the undoubted symptomatic benefit derived by hiatus hernia patients from adopting the sitting position is explained by improved clearance of regurgitated acid.

Does hiatus hernia affect competence of the gastroesophageal sphincter?

Abstract To measure the effect of a sliding (concentric) hiatus hernia on gastroesophageal sphincter competence, 75 patients were studied: 25 patients without esophageal symptoms and without hiatus hernia (Group A); 25 patients without esophageal symptoms but with hiatus hernia (Group B); and 25 patients with symptoms of severe gastroesophageal reflux, with or without a hiatus hernia (Group C). In Group C, 12 patients had a hiatus hernia, and 13 did not. Symptomatic patients were readily separated from asymptomatic ones both by a weaker base-line sphincter strength and by decreased sphincteric response to the stimulus of an increase in intraabdominal pressure. However, in neither the asymptomatic nor the symptomatic groups of patients could any effect of hiatus hernia be found. A hiatus hernia apparently has no effect on gastroesophageal sphincter competence. The rationale for surgical repair of hiatus hernia in patients with gastroesophageal reflux must therefore be questioned.

The assessment of oesophagitis in hiatus hernia patients.

The incidence of oesophagitis has been determined in 108 patients with sliding hiatus hernias using endoscopic, histological, and radiological criteria. Particular consideration has been given to the relationship between inflammatory disease and clinical symptoms. All the patients were attending a thoracic surgical clinic and the spectrum of disease encountered was fairly severe; over half of the cases had established strictures when first seen. The incidence of oesophagitis based on endoscopic evidence was 76·9%, while inflammatory change was noted on biopsy in 56·2% and at barium swallow in 58·3% of the patients. Oesophagoscopy proved to be the most satisfactory method of assessment; biopsy specimens were either inadequate or correlated poorly with other criteria while barium swallow was of diagnostic value only in severe oesophagitis. The main symptoms were pain, heartburn with regurgitation, dysphagia, and bleeding. Dysphagia was common due to the preponderance of patients with strictures, while obvious bleeding was very uncommon. Endoscopic oesophagitis was found in 75% of the patients with specific retrosternal pain and in 60% of those with heartburn and regurgitation. The inability to equate heartburn with oesophagitis is emphasized. The incidence of inflammatory change in patients with dysphagia was 87·2%; nearly all the cases in this group showed stricture formation.

Relation of Gastroesophageal Reflux to Yield Sphincter Pressures

Esophageal motility studies, utilizing constant catheter perfusion, with simultaneous intraluminal pH measurements were performed in 58 patients to study the relation of lower esophageal sphincter pressures to reflux. Patients with symptomatic hiatal hernias, incompetent lower sphincters in the absence of a demonstrable hiatal hernia, and prior vagotomies were compared with normal control subjects. Reflux did not occur in the control group. Reflux in the abnormal groups, as monitored by the intraluminal electrode, was associated with sphincter pressures that were significantly lower than those in the control group. Patients with the most marked degree of reflux demonstrated the lowest sphincter pressures. Variability in sphincter pressure and configuration was seen in hiatal hernia patients on repeat studies; the degree of reflux was related consistently to sphincter pressure present at the time. The relationship of reflux to low sphincter pressure was seen in all groups (hiatal hernia, incompetent lower sphincter, and postvagotomy).

ON THE CAUSE OF TERTIARY CONTRACTIONS AND RELATED DISTURBANCES OF THE ESOPHAGUS

ON THE CAUSE OF TERTIARY CONTRACTIONS AND RELATED DISTURBANCES OF THE ESOPHAGUSO. ARTHUR STIENNON, M.D.Audio Available | Share

Electrical potentials in the normal esophagus and in hiatus hernia.

THE CHANGES in electrical potential along the walls of the esophagus can be expected to reflect motor activity. The electrical activity may be recorded in a manner similar to that used in recording intraluminal pressure.1,2The present study is a comparison of hiatus hernia patients with a control group. Method Combined pressure-electrode probes were used, consisting of three open-end pressure tubes placed 5 cm or 2.5 cm apart. Silver ring electrodes were mounted adjacent to the open ends for recording the pressure and electrical potentials simultaneously from the same sites. The probe was introduced perorally into the esophagus and passed to a distance of about 50 cm distal to the upper incisor teeth. It was then withdrawn until the distal probe end was located 40 cm from the incisors. The external portion of the probe was taped to the chin. A series of recordings of pressure and electrical potentials

Intradermal B.C.G. Vaccination by Jet Injection

Tests of the response to perfusion of the oesophagus were made in 54 patients divided into three groups. Group I consisted of patients with symptomatic hiatal hernia, group II hiatal hernia patients with peptic stricture, and group III normal individuals. Each individual oesophagus was perfused at a rate of 45-65 drops per minute over 25 minutes with six solutions: normal saline, N/10 HCl, taurine conjugates of bile salts in normal saline, taurine conjugates of bile salts in N/10 HCl, glycine conjugates of bile salts in normal saline, and taurine and glycine conjugates in a ratio of 1 to 2 in normal saline. It was found that acidified taurine solutions were more irritating than acid alone. With a 2mM/l solution of taurine in acid, symptoms are produced even in controls. With a 1 mM/l solution of the same conjugates, the majority of normal people feel slight heartburn or nothing, and therefore perfusion into the oesophagus of such a solution could be used as a test for oesophagitis.

Deglutitive pressure responses in the gastroesophageal sphineters of symptomatic hiatal hernia patients

Resting pressures and pressure changes occurring with deglutition were recorded in each 0.5-cm. segment of the gastroesophageal sphincteric zone of 25 patients who had small, symptom-producing, sliding hiatal hernias. Pressures were detected by a water-filled balloon and laterally notched, water-filled polyethylene tubes attached to extracorporeal transducers and measured at end-expiration and end-inspiration. Mean maximal resting pressures in the sphincter were 10.5 cm. of water above gastric pressure (open-tip) and 21 cm. (balloon). With swallowing, a pressure decline below resting tone, indicating relaxation of subhiatal sphincteric segments, was often less pronounced than in health; slight increases occurred frequently. Contraction exceeded relaxation at the hiatus, a reverse of the findings in health. Contraction was most marked above the hiatus while relaxation became progressively less. Despite low resting sphincteric pressure (which probably predisposes to gastroesophageal reflux), impairment of the ability of the sphincter to relax, in addition to increases above resting tone in its subhiatal segments after deglutition, may produce an element of “functional obstruction” in some symptomatic hiatal hernia patients. Motor dysfunction of the body of the esophagus was frequent: 14 of the 25 patients studied exhibited severe or moderate derangements of contraction.

The hazard of associated esophageal hiatal hernia in patients operated on for abdominal disease

The hazard of associated esophageal hiatal hernia in patients operated on for abdominal disease

Incidence of hiatus hernia in patients without symptoms.

IN THE evaluation of the clinical significance of the esophageal hiatus hernia, the question of how frequently this lesion exists without symptoms assumes considerable importance. In view of the increasing incidence in the diagnosis of hiatus hernia, largely due to more frequent routine use of various positional maneuvers of the patient during the roentgenologic examination of the upper gastrointestinal tract, the problem of asymptomatic hiatus hernia is of greater interest. For instance, in a recent study 1 hiatus hernia was the second most frequent diagnosis made for 3,448 patients undergoing roentgenologic study of the upper gastrointestinal tract after a barium meal. Duodenal ulcer was diagnosed in 705 patients while hiatus hernia was present in 308 patients. There is great variance of opinion in the literature as to the importance and incidence of asymptomatic patients with hiatus hernia. In most reports the authors present various features of the clinical picture