How should a gastroscopy report describe a patient with a 2cm hiatal hernia, no esophagitis, and a wide esophagus that allowed easy passage of the scope through the gastroesophageal junction (GEJ)?

Gastroscopy Report Documentation for 2cm Hiatal Hernia

Document the hiatal hernia as a 2cm axial/sliding hiatal hernia (Type I) with normal esophageal mucosa, noting the gastroesophageal junction (GEJ) was easily traversed and the esophagus appeared patulous without evidence of esophagitis. 1

Structured Reporting Elements

Esophagus Description

• State explicitly that the esophageal mucosa was normal with no evidence of erosive esophagitis, using the Los Angeles classification system (Grade 0) to standardize your documentation 1
• Describe the esophagus as "patulous" or "wide-caliber" to convey the dilated appearance that allowed easy scope passage 1
• Note that the scope passed through the GEJ without resistance or difficulty, which is clinically relevant information 1

Hiatal Hernia Documentation

• Measure and document the axial length of the hernia as 2cm, defined as the distance from the diaphragmatic hiatus to the proximal extent of the gastric folds 2, 3
• Specify this as a Type I (sliding) hiatal hernia, which represents 90% of hiatal hernias and involves circular displacement of the gastric cardia above the diaphragm 4
• Best practice involves examining the hernia in retroflexion to assess both the hiatal size and integrity of the gastroesophagogastric junction 1

Hill Classification Assessment

• Consider documenting the gastroesophageal flap valve (GEFV) using the Hill classification system, which correlates with hernia severity 1
• A 2cm hernia typically corresponds to Hill Grade 2-3, where the flap valve may open transiently with respiration or be barely visible 1

Sample Documentation Language

"The esophagus appeared patulous with normal-appearing mucosa throughout. No evidence of erosive esophagitis (Los Angeles Grade 0). The gastroesophageal junction was located 2cm proximal to the diaphragmatic hiatus, consistent with a 2cm Type I (sliding) axial hiatal hernia. The scope passed easily through the GEJ without resistance. Retroflexed view confirmed the hernia size and demonstrated [describe Hill grade if assessed]. No Barrett's esophagus identified." 1

Clinical Context and Pitfalls

• A 2cm hiatal hernia is clinically significant - studies show that hernias ≥2cm are present in 96% of Barrett's esophagus patients versus only 42% of controls, indicating this finding warrants documentation and potential follow-up 2
• The absence of esophagitis despite a 2cm hernia is noteworthy, as larger hernias typically correlate with more severe reflux and mucosal injury 5
• Avoid stating "small hiatal hernia" - be specific with measurements, as 2cm represents the diagnostic threshold for clinically significant hernias 3, 6
• The wide/patulous esophagus may reflect chronic reflux-related changes even without active esophagitis, or simply anatomic variation facilitating easy scope passage 1

Documentation Standards

• Photo-document the hernia, particularly in retroflexion, as visual evidence supports your measurements and classification 1
• Include the distance from incisors to the GEJ and to the diaphragmatic impression to provide objective measurements 1
• Note whether gastric decompression was performed, as this optimizes visualization of the true extent of gastric folds and hernia size 1