What symptoms would a patient with hiatal hernia experience during unsedated endoscopy?

From the Guidelines

A patient with hiatus hernia undergoing endoscopy without sedation would likely experience significant discomfort, gagging, and a sensation of pressure when the endoscope passes through the esophageal hiatus where the hernia is located. This discomfort is due to the anatomical alteration of the gastroesophageal junction, where stomach tissue has protruded upward through the diaphragm, as noted in the personalized approach to the evaluation and management of GERD symptoms 1. They may feel increased throat irritation, chest discomfort or pain, and possibly a heightened gag reflex compared to patients without hiatus hernia. The procedure requires inspection for erosive esophagitis, diaphragmatic hiatus, axial hiatus hernia length, and inspection for Barrett’s esophagus, which can be challenging without sedation 1. Patients might also experience regurgitation of stomach contents during the procedure due to the compromised lower esophageal sphincter function associated with hiatus hernia.

• Key factors contributing to discomfort include:
  • Anatomical alteration of the gastroesophageal junction
  • Potential for increased air insufflation to visualize the area, leading to bloating and discomfort
  • Compromised lower esophageal sphincter function
  • Possible regurgitation of stomach contents While the procedure remains safe without sedation, patients with known hiatus hernia might benefit from at least minimal sedation to improve comfort, especially if the hernia is large or symptomatic, as suggested by the expert review on the personalized approach to the evaluation and management of GERD symptoms 1. Topical throat anesthetics like lidocaine spray can help reduce the gag reflex but won't eliminate the discomfort associated with the hernia itself.

From the Research

Symptoms Experienced by Patients with Hiatus Hernia Undergoing Endoscopy without Sedation

• Patients with hiatus hernia may experience discomfort or pain during endoscopy due to the presence of the hernia, as the endoscope may put pressure on the hernia or the surrounding tissues 2.
• The symptoms experienced by patients with hiatus hernia during endoscopy may be similar to those experienced by patients with gastroesophageal reflux disease (GERD), including chest pain, difficulty swallowing, and regurgitation of food 2.
• However, the study by 2 found that the symptoms of patients with gastroesophageal mucosal prolapse (GEMP) differ from those of patients with GERD, although the difference was not significant enough to allow for differentiation between the two conditions based solely on symptoms.
• The use of sedation during endoscopy can help to reduce discomfort and anxiety in patients, and midazolam is a commonly used sedative agent for this purpose 3, 4, 5.
• However, the question specifically asks about patients undergoing endoscopy without sedation, so the symptoms experienced by these patients may be more pronounced due to the lack of sedation.

Endoscopic Diagnosis of Hiatus Hernia

• The endoscopic diagnosis of hiatus hernia is not always consistent with the esophageal manometric diagnosis, and may lead to overdiagnosis 6.
• The study by 6 found that the mean and maximum hiatus hernia lengths measured by esophageal manometry were significantly lower than those measured by endoscopy, particularly for smaller hernias.
• This discrepancy may be due to the fact that endoscopy is typically performed under deep inspiration, which can cause the hernia to appear larger than it actually is 6.

Limitations of the Studies

• The studies cited above have some limitations, including the fact that they were primarily focused on the use of sedation during endoscopy, rather than the symptoms experienced by patients with hiatus hernia undergoing endoscopy without sedation 3, 4, 5.
• Additionally, the study by 2 found that the symptoms of patients with GEMP differ from those of patients with GERD, but the difference was not significant enough to allow for differentiation between the two conditions based solely on symptoms.
• Further studies are needed to fully understand the symptoms experienced by patients with hiatus hernia undergoing endoscopy without sedation.