Small Hiatal Hernia Research Articles

Pneumatosis cystoides intestinalis

A 51-year-old woman with no significant history of disease had been suffering from constipation for the past year, and had abdominal strain and rectal tenesmus during the past three days. During the examination, the only significant symptom was pain in the epigastrium and in the left iliac fossa with no reaction or peritonism. A complete blood test was performed, which showed normal results, including thyroid hormones. Gastroscopy revealed the presence of a small hiatal hernia without complications, and a Helicobacter pylori-associated erosive duodenitis, which was treated with the standard eradicating treatment. An ileum-deep colonoscopy showed 2 polyps in the ascending colon and 4 in the sigma, all of them small in size that were subsequently treated with argon. In the descending colon several elevated areas of different sizes were identified, covered by normal mucosa that collapsed after puncturing with a sclerosis and aspiration needle, which suggested pneumatosis of the colon (Figs. 1 and 2). Pneumatosis cystoides intestinalis (PCI) is defined as the presence of gas-containing cysts in the submucosal and serosal layers of the small and large bowel. The first description was given by Du Vernoin as a post-mortem observation (1). It is a rare disease of uncertain etiology. In 1974 Shallal et al. collected 410 cases from the literature (2). For unknown reasons it is more frequent in men aged between 30 and 50, and gas may remain in the cysts for long periods. Three theories exist (3) to explain the pathogenesis of PCI: the mechanical theory, which states that the gas, coming both from the intestinal lumen and the serosal layer, dissects the intestinal mucosa; the bacterial theory, according to which the gas formed by bacteria accesses the submucosa through small erosions; and finally, the biochemical theory, which suggests that bacteria in the intestinal lumen produce high quantities of hydrogen gas from carbohydrate fermentation. In many cases, PCI is a casual finding. When symptoms exist, the most frequent are: diarrhea, mucous secretion, rectal bleeding, constipation, pain, and abdominal strain. PCI in the small bowel may cause complications in the ileum, invagination, volvulus, and partial or total obstruction (1). The diagnosis can be made with plain abdominal X-rays, opaque enema, CAT, ultrasonography, MRI, and colonoscopy, although abdominal X-rays is the most reliable examination (4). Asymptomatic patients do not need any specific treatment. Symptomatic patients may be treated with high oxygen flow

Relação entre o tamanho de hérnia hiatal e tempo de exposição ácida esofágica nas doenças do refluxo erosiva e não-erosiva

In the last few years studies have demonstrated that hiatal hernias have an important role in the pathogenesis of reflux disease, promoting reflux by many different mechanisms, emphasizing that the larger the hiatal hernia, the higher the reflux intensity and erosive esophagitis prevalence. To correlate the size of hiatal hernias (small or large) with reflux intensity (measured by pH monitoring parameters) in patients with non-erosive and erosive reflux disease. We reviewed pH monitoring from patients with typical reflux symptoms (heartburn) previously submitted to upper endoscopy. Reflux intensity was measured by the % of total time of pH < 4 (%TT) and by % of time of pH < 4 in upright (%UT) and supine (%ST) positions. Patients were classified as non-erosive reflux disease if no erosive esophagitis was found in endoscopy and pH monitoring was abnormal and as erosive reflux disease if they had erosive esophagitis. Hiatal hernias were classified as small if their size ranged from 2 to 4 cm and large if > or = 5 cm. A total of 192 patients were included, being 115 in erosive reflux disease group and 77 in non-erosive reflux disease group. In erosive reflux disease patients, there were 94 (81%) with small hiatal hernias and 21 (19%) with large ones and in non-erosive reflux disease patients there were 66 (85%) with small and 11(15%) with large hiatal hernias. In erosive reflux disease group, the %TT, %UT and %ST were of 13.1 +/- 7.1; 13.4 +/- 7.4 and 12.3 +/- 11.5 in small hiatal hernias and 20.2 +/- 12.3; 17.8 +/- 14.1 and 20.7 +/- 14.1 in large hiatal hernias, respectively (P < 0.05 for %TT and %TS). In non-erosive reflux disease patients, %TT, %UT and %ST were 9.6 +/- 4.8; 10.8 +/- 6.8 and 8.6 +/- 7.3 in small hiatal hernias and of 14.6 +/- 13.3; 11.2 +/- 7.5 and 18.1 +/- 21.0 in large hiatal hernias respectively (P < 0.05 for %TT and %TS). Large hiatal hernias increase acid exposure time only in supine position in erosive esophagitis patients and in non-erosive patients.

Intermittent Spatial Separation of Diaphragm and Lower Esophageal Sphincter Favors Acidic and Weakly Acidic Reflux

In small hiatal hernias, the size of the hernia is variable. Intermittent complete reduction can be observed with high-resolution manometry as a transition from a double-peak (hernia) to a single-peak (reduced) high-pressure zone. The aim of this study was to investigate whether intermittent separation of the diaphragm and lower esophageal sphincter (LES) favors the occurrence of gastroesophageal reflux. In 16 patients with a small hiatal hernia (3 cm), prolonged high-resolution manometry was performed. Acid and weakly acidic reflux episodes were detected with pH-impedance monitoring. The single pressure peak profile (reduced hernia) was present for 814 minutes (56.5% of total time), and the double peak profile (unreduced hernia) was present for 626 minutes (43.5% of total time). In all patients, both pressure profiles were observed. The transition rate between the 2 profiles was 7.5 +/- 0.9 per hour. More reflux occurred when the LES and diaphragm were separated versus the reduced hernia state (23.1 +/- 5.1 vs 12.2 +/- 2.4 episodes per hour, respectively; P < .05). The proportions of acidic reflux episodes during the single and double pressure peaks were similar (70% and 67%, respectively). In the two-pressure-zone state, there was an increase in all reflux mechanisms except transient LES relaxation. In patients with a small hiatal hernia, intermittent reduction of the hernia occurs frequently. Spatial separation of the diaphragm and LES in the nonreduced state results in a 2-fold increase in acidic and weakly acidic reflux due to mechanisms other than transient LES relaxation.

Is Routine Preoperative Upper Endoscopy in Gastric Banding Patients Really Necessary?

Preoperative evaluation for bariatric surgery is complex. Our investigation focused on the necessity for upper gastrointestinal (GI) endoscopy as a routine procedure before performing gastric banding. A consecutive series of 145 patients underwent laparoscopic adjustable gastric banding (LAGB). Gastroscopy was performed routinely before LAGB. All patients were interviewed before gastroscopy regarding gastroesophageal symptoms. Gastroscopic findings and the results of the interview were blinded and set in comparison. Furthermore, we analyzed whether upper GI symptoms, BMI, age or gender were predictive parameters for pathological findings on gastroscopy. Small hiatal hernia was not considered a clinically relevant finding. Gastroscopy yielded abnormal findings in only 15 patients (10%). There were 8 patients with hiatal hernia, 4 patients with esophagitis, 1 gastric ulcer, 1 erosive gastritis, and 1 gastric polyp. Abnormal findings on gastroscopy did not correlate with age, BMI, or gender. The 18 patients who reported gastroesophageal symptoms were more likely to have abnormal gastroscopic findings (P<0.001). Gastroesophageal symptoms had a sensitivity of 80% and a specificity of 98% in the prediction of a GI abnormality. The data suggest that it may not be necessary to continue performing gastroscopy in all patients preparing for gastric banding. The data collected support the policy of a selective use of gastroscopy, only focusing on patients suffering from gastroesophageal symptoms. By following this strategy, the rate of preoperative gastroscopies can be reduced safely by 80%.

Endoluminal fundoplication (ELF) – evolution of EsophyX™, a new surgical device for transoral surgery

A novel endoluminal fundoplication (ELF) technique using a trans‐oral and fastener‐deploying device (EsophyX™, EndoGastric Solutions) was developed and evaluated for feasibility, safety and the treatment of gastroesophageal reflux disease (GERD) in a series of bench, animal, human (phase 1, phase 2, commercial registry) studies. The studies verified biological compatibility, durability and non‐toxicity of the polypropylene fasteners as well as the feasibility of the ELF technique. The results of the preclinical testing indicated that the EsophyX™ device was shown to be safe, and capable of deploying fasteners directly into tissue and forming an interrupted suture line at the base of the gastro‐esophageal valve (GEV). Moreover, the studies demonstrated that the ELF technique performed using the EsophyX™ device resulted in the creation of new GEVs of 3–5 cm in length and a circumference of 200°–310°, which maintained their anatomical aspects at six months. The ELF‐created GEVs appeared similar to those created by laparoscopic anti‐reflux surgery (LARS). The ELF procedure also resulted in reduction of all small hiatal hernias (⩽2 cm in size) and restoration of the angle of His. The ELF procedure provides an anatomical approach similar to that of LARS for the treatment of GERD.

Short Segment Hiatal Hernia: Is It a Clinically Significant Entity?

Background: It is a well accepted idea that hiatal hernia (HH) has a very important contributory role for the development of GERD. However, the clinical significance of small simple sliding HH has been less well studied and still is not clear. Many patients with small HH¡¯s are believed to be asymptomatic and clinically insignificant. Aim: This study was done to clarify the clinical significance of short segment (i.e. shorter than 2.0 cm in length) HH (SSHH), especially in relation to clinically significant GERD. Methods: Consecutive 4592 cases (M:F 2076:2516, median age 49 years with interquartile range 39~60 years) who underwent their initial routine diagnostic UGI endoscopy at our hospital from various indications were included. Presence and length of sliding HH were determined in each case during insertion of the endoscope while in quiet breathing without retching. Age, gender, presence of erosive esophagitis (EE), and presence of endoscopic columnar-lined esophagus (CLE) were analyzed according to the observed lengths of HH. Among them, 219 cases underwent ambulatory esophageal pH monitoring, and the results were also analyzed. Results: Among 4592 cases, 4164 cases (90.7%) had no HH, 255 cases (5.6%) had SSHH, and 173 cases (3.8%) had long segment HH (LSHH). More males were found in SSHH and LSHH groups than in non-HH group. Ages were older in LSHH group than in other groups. EE was found in 198 cases (4.8%) of non-HH group, 56 cases (22.0%) of SSHH group, and 64 cases (37.0%) of LSHH group (p < 0.001 between groups). CLE was found in 598 cases (14.4%) of non-HH group, 93 cases (36.5%), and 42 cases (24.3%) (p < 0.001 between non-HH group and other groups, p = 0.008 between SSHH and LSHH groups). High Johnson-DeMeester score was significantly less commonly found in non-HH group (26.9%) than in other groups (54.2%, p = 0.006, in SSHH group and 53.8%, p = 0.038, in LSHH group), but no difference was noted between SSHH and LSHH groups. Conclusion: LSHH is not a clinically silent and innocent entity, but it is deserved to be accused as a clinically significant pathologic entity quite similar to LSHH as far as GERD is concerned. Background: It is a well accepted idea that hiatal hernia (HH) has a very important contributory role for the development of GERD. However, the clinical significance of small simple sliding HH has been less well studied and still is not clear. Many patients with small HH¡¯s are believed to be asymptomatic and clinically insignificant. Aim: This study was done to clarify the clinical significance of short segment (i.e. shorter than 2.0 cm in length) HH (SSHH), especially in relation to clinically significant GERD. Methods: Consecutive 4592 cases (M:F 2076:2516, median age 49 years with interquartile range 39~60 years) who underwent their initial routine diagnostic UGI endoscopy at our hospital from various indications were included. Presence and length of sliding HH were determined in each case during insertion of the endoscope while in quiet breathing without retching. Age, gender, presence of erosive esophagitis (EE), and presence of endoscopic columnar-lined esophagus (CLE) were analyzed according to the observed lengths of HH. Among them, 219 cases underwent ambulatory esophageal pH monitoring, and the results were also analyzed. Results: Among 4592 cases, 4164 cases (90.7%) had no HH, 255 cases (5.6%) had SSHH, and 173 cases (3.8%) had long segment HH (LSHH). More males were found in SSHH and LSHH groups than in non-HH group. Ages were older in LSHH group than in other groups. EE was found in 198 cases (4.8%) of non-HH group, 56 cases (22.0%) of SSHH group, and 64 cases (37.0%) of LSHH group (p < 0.001 between groups). CLE was found in 598 cases (14.4%) of non-HH group, 93 cases (36.5%), and 42 cases (24.3%) (p < 0.001 between non-HH group and other groups, p = 0.008 between SSHH and LSHH groups). High Johnson-DeMeester score was significantly less commonly found in non-HH group (26.9%) than in other groups (54.2%, p = 0.006, in SSHH group and 53.8%, p = 0.038, in LSHH group), but no difference was noted between SSHH and LSHH groups. Conclusion: LSHH is not a clinically silent and innocent entity, but it is deserved to be accused as a clinically significant pathologic entity quite similar to LSHH as far as GERD is concerned.

Mechanism of altered cytokine secretion from monocytes of patients heterozygous and homozygous for CFTR mutations: Potential role in chronic inflammatory disorders

Introduction Intragastru balloon systems have been used tot weight loss m obese patients. Because of a high complication rate this method was abandoned in the 1980s. Recently, a new generation of intragastric balloon system has been introduced in clinical use. We report the eNciency and tolerance of the Bioenterics lntragastric Balloon System (BIB). Methods Obese patients willing to reduce weight wetv oticred the possibility of weight reduction assistance by the BIB Initially a questionnaire was completed by all patients, inquiring about medical history, comorbidiv, dietary' habits and previous treatment t0r obesity. BIB placement was pertormed during upper endoscopy on an outpatient basis under intravenous sedation. The system was tilled with 500ml saline, coloured with methyienblue to identity, any leakage, A dieticians consultation was pertomled every month. lhe BIB was removed endoscopically aher 6 months Weight loss was a s se~d each month and alter removal ot the BIB. Results From July 2001 to November 2002, 60 Patients (19 male, 49 iemale, mean age 44.2 years (range 26 67)) underwent BIB iruplacement. Mean initial BMi was 38.6 kg/ru 2 (range 2952) witil a mean imtial excess weight of 41.8 kg (range 13-80) and nman initial %excess wright ot 3 5 8 (133-549) Iniual upper endoscopy was normal in 43 and abnormal in 17 patients (9 esophagitis, 3 small hiatal hernia, 4 gastritis, 3 duodenal ulcers, 2 patienl:s with double pattmlognes). In all 60 patients the insertion procedure was uneventful, in 2 patients the BIB had to be removed within the first week due to intolerance, in the retraining 58 patients the mean intmgastric residing time of tbe BIB was 6 6 months (range 4.5-9.0). There was no spomaneons loss ot the device. The mean weight loss was l l .2kg (range 035~ corresponding to a %excess weight loss of 30% (0-116.7). In the first week of treatment 48 patients (82%) suffered t~rom vomiting over a mean time of 3 7 days, heartburn occurred in 13 patients (22%) and hospitalisation was necessary m 2 patients Vomiting and heartburn requinng PPi-therapy lasted longer than one week in 8 (13%) and 14 (24%) patients, respectively No major complications like pertoration or obstruction were observed. Conclusion [he insertion of BIB offers a highly efhcient method tot rapid weight reduction in obese patients Vomiting and retlux s}~nptoms are common within the tirst 4 days alter placement, but can be controlled by drug therapy Overall, the therapy is well tolerated, sate and associated with a low complication rate.

The infant with chronic vomiting: the value of the upper GI series

Vomiting is very common in infants. It is usually attributed to gastroesophageal reflux and no radiological evaluation is performed. Pediatric radiologists, however, still perform many upper GI series in these infants to exclude an underlying anatomic abnormality as a cause for vomiting. To evaluate the yield of upper GI series in the evaluation of otherwise healthy infants 1 month to 1 year of age with vomiting for more than 30 consecutive days. Clinical records and upper GI reports of 344 otherwise healthy infants that were referred for UGI by pediatric gastroenterologists because of chronic vomiting were analyzed. Patients with hematemesis, bilious vomiting, dysphagia, respiratory symptoms and patients that required hospitalization were excluded. Findings other than gastroesophageal reflux were seen in only 2 patients out of 344 (0.6%). In one patient duodenal stenosis was diagnosed. In another patient a small hiatal hernia was seen. The yield of upper GI in otherwise healthy infants 1 month to 1 year of age with chronic vomiting is extremely low, and the performance of the UGI in this specific group of patients may not be justified.

Acute food bolus impaction without stricture in children with gastroesophageal reflux

Background/Purpose: This report identifies a group of children in whom severe acute food bolus impaction (AFBI) was the leading symptom of gastroesophageal reflux (GER) in the absence of stricture. Methods: The esophageal structure and function of 8 patients treated for AFBI requiring endoscopic removal of alimentary foreign bodies in 6 of them (up to 4 times in 1 case) were investigated by barium meal, esophagoscopy-biopsy, pH-metering, pull-through stationary manometry, and 24-hour ambulatory manometry. The results were compared with those in a group of age-matched regular refluxers (n = 14) without AFBI. Results: Six boys and 2 girls aged 108 ± 59 months had impaction. Six children had symptoms of GER like vomiting during infancy, heartburn, or respiratory tract disease. Barium swallow ruled out stenosis in all patients and showed small hiatal hernias in 3. All had endoscopic and histologic esophagitis (moderate to severe in 6), and one had Schatzki ring. All but one (who had 8.45 mm Hg) had normal lower esophageal sphincter pressure (16.2 ± 4.7 mm Hg, mean ± SD), and all showed normal sphincteric relaxation. Esophageal body motility was not significantly different from that in regular refluxers except in 6 children in whom energetic distal peristalsis after reflux episodes could be seen particularly during the night. Three of them had amazingly powerful distal waves during the day and even stronger, simultaneous, wide and bizarre-shaped waves during sleep. Symptoms improved in all cases after antireflux medication. Four patients were cured after antireflux surgery. Conclusions: AFBI is a dramatic but practically unheard of symptom of GER in children. It should be differentiated from dysphagia and reveals motor dysfunction, sometimes severe, of the esophageal body in the absence of sphincteric obstruction. Antireflux medication or surgery were uniformly successful in our patients. J Pediatr Surg 36:1397-1400. Copyright © 2001 by W.B. Saunders Company.

Small bowel adenocarcinoma

A 50-year-old man with schizophrenia presented with episodic nausea, vomiting, and occasional hematemesis. A previous evaluation for a 1.5-year history of iron-deficiency anemia included a normal colonoscopy, EGD, which disclosed a small hiatal hernia and esophagitis, normal small bowel endoscopic biopsy results, and a normal small bowel radiographic contrast study. Because of recurrent symptoms with continued iron-deficiency anemia, push enteroscopy under fluoroscopy was performed, revealing a circumferential, nearly obstructing mass with ulceration in the jejunum 30 to 40 centimeters distal to the ligament of Treitz (A, B). Biopsy specimens from the mass showed moderately differentiated adenocarcinoma (C, H & E, high-power field). The patient subsequently underwent surgical resection of the tumor. Histopathologic evaluation of the resection specimen disclosed invasion into the serosa but no metastatic lymph nodes.

Role of diaphragmatic crura and lower esophageal sphincter in gastroesophageal reflux disease: manometric and pH-metric study of small hiatal hernia.

The rapid pull-through (RPT) technique during esophageal manometry helps to identify various pressure profiles of hiatal hernia (HH), based on the presence of two high pressure zones: the diaphragmatic crura (DC) and the lower esophageal sphincter (LES). Our aim was to correlate different HH profiles with frequency of reflux episodes in patients with gastroesophageal reflux disease (GERD). Seventy-eight patients with GERD and HH underwent esophageal manometry with RPT and were grouped according to the prevalent pressure profile of HH. Twenty-four-hour pH-metry served to quantify traditional (TR) and nontraditional refluxes (drop of 1 pH unit with pH > 4 or pH < 4 and time < 5 sec) (NTR) during total, upright, and recumbent periods. The group with a prevalent "flat" HH profile, representing LES and DC impairment, had significantly more TRs in total time of reflux (P < 0.01) and in recumbent and upright periods (P < 0.05) compared to the group with a prevalence of the two pressure peaks, corresponding to LES and DC efficiency. However, the group with the flat profile had significantly more NTRs + TRs than the group with pressure peaks in total time (P < 0.01) and recumbent position (P < 0.001) but not in the upright position. Hiatal hernia predisposes to GERD, but only the associated impairment of the LES and diaphragmatic crura pressures represents a condition of high risk for gastroesophageal reflux events.

Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases.

To summarize the authors' laparoscopic experience for paraesophageal hernia (PEH). Laparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accounts for approximately 5% of all hiatal hernias. Medical management may be associated with a 50% progression of symptoms and a significant death rate. Conventional open surgery has a low death rate, but complications are significant and return to routine activities is delayed in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with a lower complication rate, a shorter hospital stay, and faster recovery. From July 1995 to February 2000, 100 patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores. There were 8 type II hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-related death at 5 months from a perioperative stroke. Intraoperative complications included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pump inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respectively (normal, 50). This report represents the largest series to date of laparoscopic repair of giant PEH. In the authors' center with extensive experience in minimally invasive surgery, laparoscopic repair of giant PEH was successfully performed in 97% of patients, with a minimal complication rate, a 2-day length of stay, and good intermediate results.

Correlation between manometric morphology of small hiatal hernia and gastroesophageal reflux

Correlation between manometric morphology of small hiatal hernia and gastroesophageal reflux

Gastroesophageal reflux and Barrett's esophagus in adults born with esophageal atresia.

Postoperative morbidity after correction of esophageal atresia is partly determined by gastroesophageal reflux disease, which has been proven to affect from one-half to two-thirds of patients during childhood. We conducted a follow-up study to test our hypothesis that, if former patients still show gastroesophageal reflux at adult age, they are at high risk for developing Barrett's esophagus, which is considered to be premalignant. Of 69 patients born between 1971 and 1978, all having undergone a primary anastomosis, 24 had died, five of them because of aspiration. Of the 45 survivors, 39 could be traced; they all completed a questionnaire inquiring after symptoms related to the esophagus. Of these patients, 34 underwent an additional esophagogastrocopy. Only nine of the 39 patients had no symptoms at all; 30 had mild to severe dysphagia symptoms, and 13 had mild to severe reflux symptoms. Esophagogastrocopy in 34 patients revealed that the anastomosis was still recognizable in all cases, but stenoses were not found. Six patients showed a small hiatal hernia, and one a large one. The incidences of reflux symptoms (13/39, p < 0.01), reflux esophagitis (9/34, p < 0.01) and Barrett's esophagus (2/34, p < 0.001) were significantly higher than in the normal population. This group seems to be at risk for developing Barrett's esophagus. As this is the first follow-up study of a consecutive group of adult esophageal atresia patients, we think it is advisable to perform an esophagogastroscopy in all patients at adulthood until more long term follow-up data are available.

Gastroesophageal reflux and Barrett’s esophagus in adults born with esophageal atresia

OBJECTIVE: Postoperative morbidity after correction of esophageal atresia is partly determined by gastroesophageal reflux disease, which has been proven to affect from one-half to two-thirds of patients during childhood. We conducted a follow-up study to test our hypothesis that, if former patients still show gastroesophageal reflux at adult age, they are at high risk for developing Barrett’s esophagus, which is considered to be premalignant. METHODS: Of 69 patients born between 1971 and 1978, all having undergone a primary anastomosis, 24 had died, five of them because of aspiration. Of the 45 survivors, 39 could be traced; they all completed a questionnaire inquiring after symptoms related to the esophagus. Of these patients, 34 underwent an additional esophagogastrocopy. RESULTS: Only nine of the 39 patients had no symptoms at all; 30 had mild to severe dysphagia symptoms, and 13 had mild to severe reflux symptoms. Esophagogastrocopy in 34 patients revealed that the anastomosis was still recognizable in all cases, but stenoses were not found. Six patients showed a small hiatal hernia, and one a large one. The incidences of reflux symptoms (13/39, p < 0.01), reflux esophagitis (9/34, p < 0.01) and Barrett’s esophagus (2/34, p < 0.001) were significantly higher than in the normal population. CONCLUSIONS: This group seems to be at risk for developing Barrett’s esophagus. As this is the first follow-up study of a consecutive group of adult esophageal atresia patients, we think it is advisable to perform an esophagogastroscopy in all patients at adulthood until more long term follow-up data are available.

Manometric study of hiatal hernia and its correlation with esophageal peristalsis.

The pathogenesis of gastroesophageal reflux disease (GERD) is considered multifactorial, but alterations of the esophagogastric junction (EGJ) and hiatal hernia play a prominent role. The correlations between hiatal hernia and the other pathogenetic factors are as yet unclear, and they need to be investigated by a methodological approach based on new anatomic and functional criteria. Our aim was to study, by stationary manometry, the relationships between small reducible hiatal hernia, identified by endoscopy, and esophageal peristalsis, in patients with and without GERD. According to the absence or presence of esophagitis (E), and the absence or presence of hiatal hernia (H), 58 subjects were divided into four groups: controls 10; H 14; E 10; and HE 24. Stationary manometry was performed by the rapid pull-through (RPT) technique, with catheter water perfused, to study the lower esophageal high pressure zone [lower esophageal sphincter (LES) and diaphragmatic crura] and the parameters of esophageal peristalsis. In patients with hiatal hernia, the various combinations of peak and/or deflection of manometric line pressure identified five EGJ profiles, only one of which reveals (by one-peak profile due to superimposed LES and diaphragmatic crura) the reducibility of the hernia. The frequency of the five profiles was calculated in the HE and H groups: a two-peak profile was significantly more prevalent in these patients, although less so in the group with esophagitis. In E patients the distal amplitude and the distal propagation of esophageal waves were significantly lower than in the other three groups (P < 0.05 vs controls and group HE; P < 0.01 vs group H). Furthermore, the distal amplitude was significantly higher in the group H than in the HE (P < 0.01). Our results show a better definition of hiatal hernia morphology, via the RPT technique, disclosing five pressure profiles. In addition, a significant link was found between small reducible hiatal hernia without GERD and wave amplitude of the distal esophagus. The amplification of peristaltic clearing may be considered the initial protective process against acid reflux; the breakdown of this mechanism may trigger the pathological sequence of GERD.

Hiatal hernia size affects lower esophageal sphincter function, esophageal acid exposure, and the degree of mucosal injury

Since the role of a hiatal hernia in the pathophysiology of gastroesophageal reflux disease (GERD) has not been fully elucidated, we studied the effects of hiatal hernias on the function of the lower esophageal sphincter (LES) and esophageal acid clearance. Ninety-five consecutive patients with GERD diagnosed by 24-hour pH monitoring underwent upper gastrointestinal series (UGI), endoscopy, and esophageal manometry. Based on the presence (H+) or absence (H-) of a hiatal hernia on UGI series, they were divided into two groups: H+ (n = 51) and H- (n = 44). Then, using the size of the hiatal hernia, the H+ group was divided into three subgroups: I, H < 3 cm (n = 31); II, H 3.0 to 5 cm (n = 14); and III, H > 5 cm (n = 6). Esophageal manometry showed that patients with larger hiatal hernias (groups II and III) had a weaker and shorter LES and less effective peristalsis compared to patients with a small or no hiatal hernia. Prolonged pH monitoring showed that patients with larger hiatal hernias were exposed to more refluxed acid and had more severely abnormal acid clearance. Endoscopy showed more severe esophagitis among patients with GERD and hiatal hernia compared with GERD patients without hiatal hernia, and the degree of esophagitis was proportionate to the size of the hernia. Among patients with proven GERD, those with a small hiatal hernia and those with no hiatal hernia had similar abnormalities of LES function and acid clearance. In patients with larger hiatal hernias, however, the LES was shorter and weaker, the amount of reflux was greater, and acid clearance was less efficient. Consequently, the degree of esophagitis was worse in the presence of a large hiatal hernia.

The phrenic ampulla: distal esophagus or potential hiatal hernia?

The mechanics of phrenic ampullary emptying were analyzed to determine whether this structure functions in a manner similar to the tubular esophagus or a hiatal hernia. Simultaneous videofluoroscopy and intraluminal manometry of the gastroesophageal junction were done during barium swallows in 18 normal volunteers. Esophageal emptying was studied without any external influences, during abdominal compression with a cuff inflated to 100 mmHg, during a Müller maneuver, and after medication with atropine. The key finding of the study was that ampullary emptying was distinct from esophageal bolus transport in several ways: the propagation velocity of the clearing wave was slower, the maximal contact pressures achieved after luminal closure were lower and unaffected by atropine or outflow obstruction, and ampulary emptying was driven by a hydrostatic pressure difference between the ampulla and stomach rather than by a peristaltic contraction. Increased bolus volume slightly enlarged the ampulla. Taken together, these findings suggest that ampullary emptying occurs, in part, as a result of the restoration of esophageal length (presumably by tension from the phrenoesophageal membrane) rather than as a result of an aborally propagated contraction. As such, a normal phrenic ampulla is analogous to a small reducing hiatal hernia. We speculate that overt hernia formation occurs as a result of progressive degeneration of the phrenoesophageal membrane.

The value of endoscopy and endosonography in the diagnosis of the dysphagic patient.

The value of endoscopy in dysphagia is limited in the diagnosis of motility disorders and small structures, webs, and hiatal hernias. Endoscopy is of special use for the clarification of an organic cause of dysphagia. Intraluminal tumors can be seen and in a high percentage of cases be definitely diagnosed by taking biopsies; a malignant degeneration in Barrett's esophagus is detectable by endoscopy in 89.1% of cases. Gastroesophageal reflux disease can be diagnosed on endoscopy as it leads to an endoscopically visible inflammatory reaction; however, normal findings on endoscopy cannot exclude reflux disease. Endoscopy is the method of choice in the diagnosis of nonreflux esophagitis, especially Candida and viral esophagitis. A further advantage of endoscopy is the fact that a microscopic diagnosis can be obtained and endoscopic treatment can be performed simultaneously. Submucosal or extramural lesions can be missed by endoscopy. Endosonography, the combination of endoscopy and ultrasonography (EUS) yields additional information in diagnosing submucosal and extramural lesions of the esophagus which is missed by other imaging procedures. One of the main advantages of EUS is the detection of small and submucosal lesions. The most important indication is the local staging of esophageal carcinomas; the accuracy of endosonography in determining the depth of infiltration ranges between 79% and 92%. The detection of paraesophageal lymph nodes is successful in 60%-82%, although EUS cannot differentiate benign from malignant lymph nodes. Submucosal tumors can be visualized by endosonography and their size, echopattern, and the layers of origin can be determined with high accuracy. Further indications for EUS are the exclusion of focal lesions in achalasia or peptic strictures.

Delayed gastric emptying associated with gastric bezoar

A 56-YEAR-OLD man presented with a 6 month history of constant bloating epigastric pain unaccompanied by any sensation of nausea or vomiting. The pain was experienced when he assumed an upright posture and was relieved by lying supine or deep breaths. The patient also gave a history of poor apetite and lost 16 pounds of body weight over a year. His medications included cimetidine 300 mg twice a day and Mylanta PRN for abdominal pains. His other illnesses included hypertension, abdominal aortic aneursym, and mild chronic interstitial lung disease. On examination the vital signs were normal. Abdomen was negative for any masses or tenderness. Abdominal computerized axial tomography (CT) was normal. Upper gastrointestinal (GI) series were unremarkable except for a small hiatal hernia without reflux. A gastric emptying using 2 mCi of TC-99m sulfer colloid labelled to an egg meal revealed emptying half time (T 1/2) of 308 minutes. (Normal T 1/2 is 67 + 17 min (Mean _+ 1 SD, N = 8). The stability of radiolabelled egg meal in our laboratory is 94.8 _+ 2.4% at two hour post incubation in simulated gastric juice. An upper GI endoscopy revealed a vegetable bezoar. The patient underwent orogastric lavage removal of bezoar followed by intermittent nasogastric suction with relief of abdominal pain. A repeat gastric emptying study revealed gastric emptying half-time of 125 mintues and correlated with clinical improvement. Figure 1 in top row reveals the gastric emptying study when T I/2 was 308 minutes. At ten and 30 minutes after ingestion of test meal (Figs 1A and 1B) the activity is confined to fundus and on the 60 and 90 minute images some activity passes into pylorus and a filling defect in the body of the stomach is evident (Figs 1C and 1D). The filling defect probably represented bezoar. Figure 1 in bottom row exhibits followup gastric emptying study performed a week after removal of vegatabIe bezoar. The radiolabelled meal promptly fills the entire stomach and the filling defect has been markedly reduced in size. The gastric emptying half-time improved to 125 minutes. Delayed gastric emptying due to gastric bezoar is a rare condition and can be effectively treated. Depending upon the presence or absence of mechanical/anatomical obstruction the pathological conditions associated with delayed gastric emptying can be divided into obstructive and non-obstructive categories. The non-obstructive causes may also be termed gastroparesis or functional obstruction. Pathological Conditions Associated With Delayed Gastric Emptying: