From the Guidelines
The necessary workup for a diagnosis of hiatal (esophageal) hernia should include a fluoroscopy biphasic esophagram or fluoroscopy upper GI series to detect the presence and size of the hernia, as well as provide anatomic and functional information on esophageal length, esophageal stricture, presence of gastroesophageal reflux, and reflux esophagitis. This recommendation is based on the most recent and highest quality study available, which suggests that a combined technique of fluoroscopy biphasic esophagram or fluoroscopy upper GI series is the most favorable approach for assessing hiatal hernia and its complications 1.
The workup may involve the following steps:
- A thorough clinical evaluation including a detailed history of symptoms such as heartburn, regurgitation, chest pain, or difficulty swallowing
- Diagnostic testing with a fluoroscopy biphasic esophagram or fluoroscopy upper GI series to detect the presence and size of the hernia, as well as provide anatomic and functional information on esophageal length, esophageal stricture, presence of gastroesophageal reflux, and reflux esophagitis
- Additional testing such as upper endoscopy (EGD) to directly visualize the hernia and rule out complications like esophagitis, Barrett's esophagus, or malignancy may be considered, but the most recent evidence suggests that a fluoroscopy biphasic esophagram or fluoroscopy upper GI series is the most appropriate initial test 1.
The use of a combined technique of fluoroscopy biphasic esophagram or fluoroscopy upper GI series has been shown to have a high sensitivity for detecting esophagitis, with a reported sensitivity of 88% in some studies 1. This approach can provide valuable information on the size and type of hernia, as well as the presence of complications such as esophagitis or reflux esophagitis.
In cases where the hiatal hernia is large, an upper GI series evaluation should be included for complete assessment of the stomach 1. This comprehensive approach helps determine the appropriate management strategy, whether conservative treatment with lifestyle modifications and medications or surgical repair for symptomatic or complicated cases.
From the Research
Necessary Workup for Hiatal Hernia Diagnosis
The necessary workup for a diagnosis of hiatal (esophageal) hernia includes:
- Upper endoscopy: considered the gold standard for diagnosing hiatal hernias, with a sensitivity of 97.5% and a specificity of 99% 2, 3, 4
- Barium swallow: can be used to diagnose hiatal hernias, but its sensitivity and specificity are lower than those of endoscopy, and it may not provide additional information if endoscopy is performed 3
- Esophageal manometry: can be used to diagnose hiatal hernias, but its sensitivity is lower than that of endoscopy, and it is not reliable for ruling in a hiatal hernia 2, 4
- High-resolution manometry: has better specificity and ability to rule out an overt Type-I sliding hiatal hernia, but it is not reliable for ruling in a hiatal hernia 4
Diagnostic Criteria
The diagnostic criteria for hiatal hernia include:
- Separation of the gastroesophageal junction >2.0 cm from the crural diaphragm on high-resolution manometry 4
- Presence of a double high-pressure zone or double hump on stationary manometric pull-through 2
- Visualization of the hernia on upper endoscopy or barium swallow 2, 3
Preoperative Workup
The preoperative workup for laparoscopic fundoplication or hiatal hernia surgery may include:
- Symptoms questionnaire
- Videoesophagogram
- Upper endoscopy
- Manometry
- pH-metry 5