Introduction
Hiatal hernia (HH) is frequently associated with gastroesophageal reflux disease (GERD) and esophageal motility disorders. However, its functional implications on esophageal physiology remain controversial. This study aimed to assess the clinical relevance of HH and esophagogastric junction (EGJ) morphology on esophageal symptoms and function.
Aims & Methods
We conducted a cross-sectional, observational study comparing esophageal function in patients with and without hiatal hernia in 92 patients referred for high-resolution manometry (HRM) and 24-hour pH monitoring. Fifty-five patients with HH were compared to 37 controls without HH. Patients were also classified by EGJ morphology (types I, II, III). Clinical evaluation included validated symptom questionnaires: GERD-Q, Eckardt, and BED-Q. Patients with prior esophagogastric surgery or EGJ outflow obstruction were excluded. Comparative analysis employed chi-square tests for categorical variables, and Student’s t-test, ANOVA, or Kruskal-Wallis tests for continuous variables, depending on distribution.
Results
Of the 92 patients, 61 (66.3%) were female, with a mean age of 56 ± 14 years and BMI of 26.6 ± 7.5 kg/m². HH was present in 55 patients (59.8%). EGJ classification revealed 36 type I, 38 type II, and 15 type III configurations. HH was significantly associated with higher reflux symptom scores on the GERD-Q (p = 0.015) and increased esophageal acid exposure on pH monitoring (p = 0.015). Acid exposure time increased proportionally with HH size, although symptom severity (GERD-Q) did not correlate with hernia size. There were no significant differences in dysphagia scores (Eckardt or BED-Q) or total reflux episodes between groups. Similarly, EGJ morphology did not correlate with clinical, manometric, or pH-metric outcomes.
| No HH
(n = 37) | HH
(n = 55) | p-value |
| Clinical scores |
|
|
|
| GERD-Q ≥ 8 | 20 (54%) | 43 (78%) | 0.015 |
| Eckardt score ≥ 3 | 19 (51%) | 39 (71%) | 0.057 |
| Manometric findings |
|
|
|
| IRP ≥ 15 mmHg | 6 (16%) | 15 (27%) | 0.210 |
| Ineffective Esophageal Motility | 2 (5%) | 9 (16%) | 0.110 |
| pHmetry parameters |
|
|
|
| AET > 6% | 3 (8%) | 16 (29%) | 0.015 |
| Total reflux episodes > 80 | 3 (8%) | 10 (18%) | 0.150 |
AET, acid exposure time;
IRP, integrated relaxation pressure;
HH, hiatal hernia;
MNBI, mean
nocturnal basal impedance.
Conclusion
In this study, HH was associated with greater acid exposure and more severe reflux symptoms, with acid burden increasing proportionally to hernia size. However, symptom severity did not reflect hernia size, and EGJ type showed no significant functional impact. These findings underscore the pathophysiological relevance of HH in GERD, independent of EGJ subtype.
References
1. Kayali S, Calabrese F, Pasta A, et al. Effect of hiatal hernia and esophagogastric junction morphology on esophageal motility: Evidence from high-resolution manometry studies. Neurogastroenterol Motil. 2024;36(12):e14929. doi:10.1111/nmo.14929.
2. Tolone S, de Cassan C, de Bortoli N, et al. Esophagogastric junction morphology is associated with a positive impedance-pH monitoring in patients with GERD. Neurogastroenterol Motil. 2015;27(8):1175-1182. doi:10.1111/nmo.12606.