Hiatal Hernia and Gastroesophageal Reflux

THE INCIDENCE of herniation of the stomach through the esophageal hiatus of the diaphragm has been variously reported, with figures as high as 50 to 60 per cent of the adult population (3, 4). Incidence varies with the examiner and his technic. If one concedes that the incidence of hernia is high, it then is of interest to know how many such herniations are actually of clinical significance. To help answer this question, 1,027 consecutive patients referred for upper gastrointestinal examinations, excluding only a few aged or infirm individuals, were also evaluated for hiatal hernia and (using the water siphon test) for gastroesophageal reflux.

Before the radiological examination, we asked each patient to answer a questionnaire in an attempt to evaluate reported symptoms. For simplicity and ease of analysis, we made this a “yes” or “no” questionnaire, as shown in TABLE 1. The results were analyzed statistically, using the following criteria for making a diagnosis of hiatal hernia : (a) lower esophageal ring described by Schatzki seen above the diaphragm; (b) freely sliding gastric mucosa through the diaphragmatic hiatus and hence above the diaphragm; (c) a large hiatus (more than 2.5 em) in the diaphragm, and (d) the retention of barium above the diaphragm in this pouch despite peristaltic activity in the esophagus.

The following tests for demonstrating hiatal hernia or gastroesophageal reflux were employed on each patient:

Test 1: Following the ingestion of 8 ounces of barium, the patient was placed in the supine Trendelenburg position (at least 15°) and the esophagogastric junction was observed.

Test 2: While in the supine position, the patient was asked to raise his legs; the esophagogastric junction was again observed.

Test 3: With the patient horizontal, the junction was studied in the prone right anterior oblique position after a swallow of barium.

Test 4: A rounded balsa block (Fig. 1) was interposed in the abdominal region between the prone patient and the table. This was thick enough to eliminate the usual lordotic lumbar curve in most patients. The patient was then given a single swallow of barium. An identical balsa block was used for all examinations for standardization. This rather rigorous procedure, performed initially on the authors themselves, was tolerated by almost all patients with no great discomfort.

Test 5: Gastroesophageal reflux was studied by the “water siphon” test (de Carvalho maneuver) (1).

When the patient is in the supine right posterior oblique position, the barium in the stomach backs up against the esophageal orifice. If the patient then swallows water, any opaque material seen in the esophagus must have come from the stomach. The test is positive when such contrast medium appears (excluding minute traces which immediately return to the stomach).