EDITORIAL

Diagnosis of Hiatal Hernia I2t'H()UGH HI.;RNIATI()S of the st()maeh t h r o u g h the esoi)ha,zeal

hiatus was recognized by M o r g a g n i ill 1769, only recently has A the disorder received m u c h a t t e n t i o n } Considerable effort has

been spent in an a t t e m p t to set Ul) criteria for the diag'nosis of hiatal hernia, in d e t e r m i n i n g the incidence of hiatal hernia, in delineating the clinical f e a t u r e s a c c o m p a n y i n g hiatal hernia, and in a t t e m p t s to u n d e r s t a n d the functional d e r a n g e m e n t s secondary to hiatal hernia.'-' The p a p e r l)y l)rs. Stein and F i n k e l s t e i n a suggests r o e n t g e n criteria for the diagnosis of hiatal hernia and a t t e m p t s to determine the roentgen incidence of hiatal h e r n i a based u p o n these criteria. The clinical f e a t u r e s of these p a t i e n t s have been discussed 1)y Tmnen, Stein, and Nhlansky. ~ B o t h of these p a p e r s point out m a n y of the i)roblems related to the confused a n a t o m y and physioloo'y of the e s o p h a g u s and the e s o p h a g o g a s t r i e junction. ])octets Stein aml F i n k e l s t e i n classify as (lrade 1 hiatal hernia, herniation of merely the g'astroesoi)hageal vestibule. The controversial point here is w h e t h e r h e r n i a t i o n of the vestibule r e p r e s e n t s a true hernia an(l whether the r o e n t g e n a p p e a r a n c e of Grade 1 hernia ean be d i s t i n g u i s h e d froin the r o e n t g e n findings in norreal individuals. The r o e n t g e n o g r a p h s shown by l)oetors Stein and Finkelstein c o r r e s p o n d closely to the d i a g r a m m a t i c sketches t e r m e d hiatal insufficiency a in the p a p e r by E v a n s . All will agree that the diagnosis of hiatal h e r n i a cannot 1)e m a d e leisurely by routine radiogTaphie means. Stein and Finkelstein suggest the first-degree hiatal h e r n i a m a y in time p r o g r e s s to f o r m a l a r g e r hiatal hernia. These conclusions are in accordance with the o b s e r v a t i o n s of Nprafka, Azad, and Baronofsky, ~ who r e p o r t e d that 58 per cent of 19 patients folh)wed for 6 or m o r e years d e m o n s t r a t e d p r o g r e s s i o n f r o m small to large hernias. ])r. Wolf, in a recent editorial, ~ takes issue with this point of view, indicating that he is not convinced that any substantial n m n b e r of small hernias increase in size over a p e r i o d of years. The presence of r e g u r g i t a t i o n is used as a n o t h e r s u p p o r t for the definition of Grade I hiatal hernia. Stein and F i n k e l s t e i n r e p o r t NEW SERIES voL. s, No. s, ~%0

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that symptoms of pyrosis and anginal pain can be reproduced when the barium meal regurgitates from the stomaeh into the esophagus. Regurgitation is common when the stomach is overdistended or when special maneuv,,,rs are employed to increase intra-abdominal pressure. Regurgitation was reported in 50 per eent of patients with Grade 1 hiatal hernias who had symptoms and in only 20 per eent of patients with Grade 1 hiatal hernias in the absence of symptoms. 4 Conway-Hughes s observed regurgitation in 30 of 32 patients with hiatal hernia and reported an ineidenee of regurgitation in 20 per cent of patients without hiatal hernia. Many radiologists find it difficult to spell out the roentgen eriteria for the diagnosis of hiatal hernia. Certainly not all radiologists will accept the definition proposed by Doctors Stein and Finkelstein. Nonetheless there is some justifieation for their point of view based upon studies of the pathophysiology and clinical features presented by these patients. We have been particularly interested in studying the abnormalities of esophageal motor function in patients with hiatal hernia. 9, 10 Intraluminal pressures have been reeorded simultaneously from the fundus of the stomach, at the level of the diaphragm, in the herniated stomaeh, at the esophagogastric junction, and higher in the esophagus during resting and deglutative activity. Simultaneous fluoroeinematography has permitted correlation of the roentgen phenomena with the intralnminal pressure changes. Two abnormalities have been found to be characteristic of patients with hiatal hernia. The first of these is dysfunction of the esophagogastric closing mechanism. The normal "high-pressure zone" between the gastric fundus and esophagus is displaced upward in patients with sliding hiatal hernia. The pressures in this zone, which normally exceed fundie pressure, were frequently equal to those recorded from the herniated stomach, thus providing no barrier to gastroesophageal reflux. Similar findings have been reported by Atkinson e t al., 12 and Monges? "~ In addition, the characteristic physiologic behavior of the highpressure zone (relaxation of the zone following swallowing and subsequent contraction) was observed in only 20 per cent of the patients with hiatal hernia. Physiologic and roentgenographie studies indicate that the normal high-pressure zone normally straddles the diaphragm. In the presence of herniation of the gastro494

AMERICAN JOURNAL OF DIGESTIVE DISEASES

Editorial

esopha,,)'oal vestibuh,, the infradiaphragmatic portion of the highpressure zone is displaced into the thorax where it becomes less efficient as a sphincter under the influence of neg'ative intrathoraeie pressure.10.14 On inspiration only the infradiaphragmatic portion of the high-pressure zone has a pressure which exceeds fundie pressure and prevents reflux. The closing mechanism at the gastroesophageal junction was incompetent in 80 per cent of our patients with hiatal hernia as determined by the absence at this level of a zone of high pressure which exceeds fundie pressure. These observations may explain the high incidence of gastroesophageal reflux observed by Stein and Pinkelstein and by Conway-Hughes. The second motor abnormality of the esophagus found in patients with hiatal hemfia consisted of abnormal motor activity. The deglutition complexes from the distal third of the esophagus were frequently abnormal. They resembled somewhat the loweramplitude and prolonged-duration complexes that are normally recorded from the amImllary area. Frequent rhythmic, nonperistaltie contractions occurred in the absence of swallowing. The amplitude of these contractions usually exceeded that of the primary peristaltic wave. The contractions were manifested radiologically as " c u r l i n g . " It is significant that 12 of 14 patients reported to have diffuse spasm of the esophagus by Creamer, Donoghue, and ('ode ~'~ had a concurrent roentgen diagnosis of hiatal hernia. The combined studies have made possible some correlations between the clinical, physiological, and roentgen phenomena presented by tlie patient with hiatal hernia. Incompetency of the lower esophageal sphincter predisposes to gastroesophageal reflux, esophagitis, heartburn, and dysphagia. Nonperistaltie motor activity has been correlated with heartbm'n and substernal pain. The abnormality of the deglutition pressure gradient involving the lower third of the esophagus combined with the simultaneous, repetitive, contractions of excessive amplitude results in dysphagia. The broad band of elevated pressure in the herniated segment with "double-reversal phenomena" have made possible the diagnosis of hiatal hernia in patients whose roentgenograms show no evidence of abnormality2 ~ Physiologic measurements of pressure within the esophagus and at its sphincters have afforded a means NEW SERIES VOL. 5, NO. 5. 1960

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for d i s t i n g u i s h i n g between l)atients with s y m p t o m a t i c hiatal hernias and p a t i e n t s with a s y m p t o n m t i e hiatal hernias. T h e y have also a f f o r d e d the o p p o r t u l l i t y to d i s t i n g u i s h between substernal pain of esophageal ovio'in mid that of ear(tiae origin. Thu~, a l t h o u g h m a n y radiologists at p r e s e n t m a y have reservations in aeeepting the definition and conclusions of l)oetors Stei~t and Finkelstein, the physiologic a l t e r a t i o n s aeeonlpalLvillg' minimal hiatal herniation, as well as the clinical sylnptonlatoh)gy, suggest that hel"niatiol~ of m e r e l y the g a s t r o e s o p h a g e a l vestibule results in essentially the same physiologic alterations and s y m p t o m s which aeeonlpal~y laro'er hiatal hernias. Our concepts of some esophag'eal disovdel"s are in the process of being a l t e r e d and as f u r t h e r eovrtdative studies are ohtained these eoneei)ts will ~1o doubt be altered f u r t h e r . E. (.'IANTON TEXTEII, ,ILL, M.I)., a n d \VII,LL~,M E. BUXI)ESEX, 3I.D. Departmt'~Hs o.t 3[edi<'i~e a~d Radiolog.!! Northw~'ster~ U~Hcersit!t M(,die~d Ce~zter

REFERENCES l. 2.

:~. 4.

5. Ik 7. S.

9. 10.

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EDS~UXl)S, V. I I i a t u s h e r n i a : A (.linic'd s t u d y of '20(~ cases. Q ~ r t . d . . l l ~ d . ~.s. 46:445, 1957. Bioliotheca G a s t r o e n t e r o l o g i a . F;isc. 1. I)iag~ox,, und TlH.ral~i, d,r Itiot~¢shcrnia. Basel, S. K n r g e r , 1960. STEIN, (~..'N~., ~lnil ~'INKELSTEIX, A. H i a t a l h e r n i a : R o e n t g e n incidence a n d diagl~osis. ~l m. J. Dig(.st. Dis. ~.x. ,~:77, 1960. "FVMEN, H. ,J., STEIN, I.T.N., and .QHLANSI
Editorial 12. ATKIXSOX. 3[., ED~VARDS, ]). A. W., Hoxotm, A. J., and ROWLANDS. E. N. The Oesophagogastric sphincter in hiatus hernia. Latlcet z~:1138, 1957. 13. MONGES, H. Donn6es anatomiques, radiologiques et lfl~ysiologiques ~ur l'hiatus oesophagien. Bibl. (;a.,tro(~tlt. 1:3, Karger, Basel, 1960. 14. V.\NTRAPPEN, G., TEXTER, ~]. C., JR., BARBORKA, C. g., and VANDENBROUCKE, J. The closing mechanism at the gastroesophageal junction. A m . J. Med. (in press). 15. CREA:,IER,B., DONOGHUE, F. E., and CODE, C. F. Pnttern of esophageal motility in diffuse spasm. Ga.~troe~tterology 34:782, 1958. I{L OLSEX, A. M., CODF, C. F., and CLAOETT, O. T. Role of motility patterns in the di:lgnosis of esophageal disease. J . A . M . d . 172:819, 1960.

MEETINGS AND CONGRESSES AMERICAN MEDICAL ASSOCIATION Section on Gastroenterology Miami Beach, Fla. June 13-17, 1960 2:00 2:15 2:30

3:30

Tuesday Afternoon--June 14, 1960 Vatal Gastrointestinal Bleeding. ~[ARCEL PATTEI~SOX,KEXxl.:TH ~VEExEX, and EI,I ZoxaxA, (lalveston, Tex. A Survey of the End-Results of Treatment of Careinonm of the Stomach. WILLIAM_F. ],Ivr, Buffalo, N. Y. Symposium on Postsurgieal Problems of the (;astrointestinal Tract. Esophageal Stricture and Fsophag'itis. J. ALFRED Rmf':a, San Franeiseo, Calif. Gastric Resection 1)iflieulties. THoS[AS MaCHaLLA, l'hiladelphia, Pa. Shunt Procedures for Portal Hypertension. Mat-I~iC~.: STAUFFER, Rochester, Minn. Intestinal Resections and Anastomoses. Jas~-:s BOIILANDand R. HAXCOCK, Jacksonville, Fla. lleostomy, Colostomy. J o u x llav and M. (). HIXES, New Orleans, La. 1)iseussion. Moderator, Jos,:Pn B. Kmsxl,m, Chicago, 111.

Wednesday Afternoon~June 15, 1960 2:00 Business Meeting 2:1(1 ('haivman's Address: On ~qpeeialization and Gastroenterology. JOsEpH B. Kmsxl.m, Chieago, Ill. NEW SERIES VOL. S, NO. s,

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