High-resolution manometry is superior to endoscopy and radiology in assessing and grading sliding hiatal hernia: A comparison with surgical in vivo evaluation

Abstract

Background: Hiatal hernia is diagnosed by barium-swallow esophagogram or esophagogastroduodenoscopy, with possible suboptimal results. High-resolution manometry clearly identifies crural diaphragm and lower esophageal sphincter.

Objectives: To assess the diagnostic accuracy of high-resolution manometry in detecting hiatal hernia compared to esophagogram and esophagogastroduodenoscopy, using as reference the surgical in vivo measurement.

Methods: Patients were studied with esophagogram, esophagogastroduodenoscopy, high-resolution manometry and in vivo evaluation of the esophago-gastric junction. Esophago-gastric junction was classified as type I (no separation between crural diaphragm and lower esophageal sphincter); type II (≥1, ≤ 2 cm separation); type III (>2 cm). During in vivo measurement, distance between the esophago-gastric junction and crural diaphragm proximal border was recorded.

Results: Surgery identified 53 hiatal hernias in 100 patients. Forty-seven percent were classified as type I esophago-gastric junction, 35% type II and 18% type III. Referenced to in vivo evaluation, high-resolution manometry showed superior diagnostic sensitivity and specificity (94.3% and 91.5%, respectively) to esophagogram and esophagogastroduodenoscopy, with 92.6% predictive value of a positive test and 93.5% predictive value of a negative test. The kappa value for high-resolution manometry and in vivo evaluation was 0.85. High-resolution manometry showed optimal sensitivity and specificity in detecting types I, II and III esophago-gastric junction.

Conclusions: High-resolution manometry enables an accurate diagnosis of hiatal hernia and a better classification than endoscopy and radiology, reaching optimal agreement with in vivo assessment.

Keywords: Hiatal hernia; barium esophagogram; esophagogastric junction; high resolution manometry; upper endoscopy.

Figure 1.

Examples of high resolution manometry traces in (1) esophagogastric junction (EGJ) morphology type I (complete overlap between lower esophageal sphincter and crural diaphragm); (2) EGJ morphology type II (separation > 1 but ≤ 2 cm); (3) EGJ morphology type III (separation > 2 cm).

Figure 2.

Intraoperative recording of esophagogastric junction (EGJ) landmarks (proximal rugal fold and crural diaphragm) by means of intraoperative endoscopy.

Figure 3.

Hiatal hernia presence and esophagogastric junction appearance during in vivo examinations and during different diagnostic testing. EGJ: esophagogastric junction; HRM: high-resolution manometry; EGD: esophagogastroduodenoscopy.

Figure 4.

(a) Receiver operating characteristic (ROC) curve for the presence of hiatal hernia by high resolution manometry (HRM), using in vivo surgical assessment as diagnostic reference. AUC: area under the curve. (b) Area under receiver operating characteristic(AUROC) curve for the presence of hiatal hernia by the measurements of lower esophageal sphincter to crural diaphragm (LES–CD) length at high-resolution manometry (HRM), upper endoscopy (UE) and barium esophagogram (BE).