Effect of hiatal hernia on esophageal manometry and pH-metry in gastroesophageal reflux disease

Abstract

An increased frequency of reflux events and a prolonged acid clearance have been shown in gastroesophageal reflux (GER) patients with a hiatal hernia as compared to those without. The objective of the present study was to further investigate esophageal motility and patterns of reflux in GER patients, in relation to the presence or absence of hiatal hernia. Esophageal manometry and ambulatory 24-hr esophageal pH-metry were used in 42 patients with GER and 18 controls. Eighteen of the patients were considered to have a nonreducing hiatal hernia on endoscopy. Hiatal hernia patients showed a higher extent of reflux (total composite score, P = 0.016; total reflux time, P = 0.008, reflux time in supine position, P = 0.024; reflux time in upright position, P = 0.008), a lower frequency of reflux events (P = 0.005), a more severe esophagitis on endoscopy (P < 0.01) and a lower amplitude of peristalsis at 5 cm proximal to LES (P = 0.0009) as compared to patients without hiatal hernia. The amplitude of peristalsis at the distal esophagus was inversely related to the extent of reflux (P = 0.024). Acid clearance was also significantly prolonged in the hernia subgroup (P = 0.011). Although LES resting pressure did not differ significantly between the two subgroups of patients, it was inversely related to the extent of reflux in the patients with hiatal hernia (P = 0.0005). It is concluded, that GER patients with hiatal hernia present with an increased amount of reflux and more severe esophagitis, which results in more severely impaired esophageal peristalsis as compared to patients without hernia. Prolonged acid clearance and impaired esophageal emptying observed in patients with hiatal hernia could be the result of both the presence of the hernia itself and the reduced peristaltic activity of the esophagus.

Esophageal Acid Exposure in Upright and Recumbent Postures: Roles of Lower Esophageal Sphincter, Esophageal Contractile and Transport Function, Hiatal Hernia, Age, Sex, and Body Mass

“…It also contrasts with the results of a study on 95 patients in which subjects with hiatal hernias ≥ 3 cm were found to have a more abnormal refluxate clearance than subjects without a hernia or with a hernia <3 cm [32]. Further, the acid exposure time [33][34][35][36], the incidence of pathological reflux [38], and the frequency or severity of esophagitis [34,35] were observed to be significantly greater in patients with than in those without hiatal hernia. The failure to detect such a relationship in the present study may be due to the fact that only 30 of our 116 patients had hiatal hernias >3 cm in axial length and 41 were devoid of a hernia.…”

Esophagogastric junction distensibility: a factor contributing to sphincter incompetence

“…When examining GERD in the context of hiatus hernia, certain distinctions become evident. Patients with more severe forms of GERD, such as erosive esophagitis and Barrett's metaplasia, almost invariably have a hiatus hernia (2,18), and GERD patients with hiatus hernia have increased esophageal acid exposure compared with patients without hiatus hernia (8,18). The mechanistic profile for reflux in hiatus hernia patients is also distinct.…”

Definitions of Gastroesophageal Reflux Disease (GERD)

“…Sloan and Kahrilas employed concurrent videofluoroscopy and esophageal manometry to assess the impact of hiatal hernias on esophageal emptying, finding impaired esophageal emptying in nonreducing hernias compared to controls due to "late retrograde flow," suggesting impaired EGJ competence [82]. Likewise, the presence of hiatal hernias in GERD is associated with higher extent of reflux and lower amplitude of distal esophageal body peristalsis [83], while large hiatal hernias (> 3 cm) are associated with a shorter and weaker LES compared to small or no hiatal hernias [84].…”