From the Guidelines
The workup for a patient with hiatus hernia should begin with a fluoroscopy biphasic esophagram or fluoroscopy upper GI series to detect the presence and size of the hiatal hernia, as well as provide anatomic and functional information on esophageal length, esophageal stricture, presence of gastroesophageal reflux, and reflux esophagitis. This approach is supported by the American College of Radiology, which recommends the use of fluoroscopy biphasic esophagram or fluoroscopy upper GI series as the initial diagnostic test for patients with epigastric pain, including those with hiatus hernia 1.
The esophagram can provide valuable information on the presence of reflux esophagitis, which may manifest as fine nodularity or granularity of the mucosa, erosions or ulcers, thickened longitudinal folds, inflammatory esophagogastric polyps, and scarring with strictures, sacculations, or fixed transverse folds. The sensitivity of single-contrast examinations for detecting endoscopically proven esophagitis is reported to be 77%, while double-contrast examinations have a higher sensitivity of 80% 1.
Some key points to consider in the workup of a patient with hiatus hernia include:
- The use of a combined technique, such as fluoroscopy biphasic esophagram or fluoroscopy upper GI series, to provide a comprehensive assessment of the hernia and associated complications
- The importance of assessing for reflux esophagitis and other associated conditions, such as esophageal stricture or Barrett's esophagus
- The potential need for additional diagnostic tests, such as esophagogastroduodenoscopy (EGD), esophageal manometry, or 24-hour pH monitoring, to guide management strategies
- The role of CT scanning in evaluating large hernias or complications, and laboratory tests to rule out other conditions.
Overall, a thorough clinical assessment and diagnostic testing are essential to determine the size and type of hernia, assess associated complications, and guide appropriate management strategies for patients with hiatus hernia.
From the Research
Diagnostic Approaches for Hiatus Hernia
The workup for a patient with hiatus hernia typically involves a combination of diagnostic tests, including:
- Barium swallow radiography
- Endoscopy
- High-resolution manometry
- Ambulatory impedance-pH monitoring (MII) 2
Comparison of Diagnostic Tests
Studies have compared the effectiveness of these tests in diagnosing hiatus hernia:
- Barium swallow X-ray has been shown to have the highest rate of hiatus hernia detection (76.8%) 2
- Endoscopy has been found to have a significant correlation with gastroesophageal reflux disease (GERD) 2
- High-resolution manometry has been shown to have better specificity and ability to rule out an overt Type-I sliding hiatal hernia 3
- A combination of these tests may be necessary for reliable exclusion of hiatus hernia prior to treatment 2
Specificity and Sensitivity of Diagnostic Tests
The specificity and sensitivity of diagnostic tests for hiatus hernia have been evaluated:
- High-resolution manometry has been found to have a higher specificity (95.12%) compared to endoscopy (68.29%) 3
- Endoscopy has been found to have a low sensitivity (<40%) in diagnosing sliding hiatal hernia 4
- The likelihood ratios of a positive and negative test have been found to be higher for high-resolution manometry compared to endoscopy 3
Clinical Utility of Diagnostic Tests
The clinical utility of diagnostic tests in different patient populations has been assessed: