Hiatal hernia prevalence and natural history on non-contrast CT in the Multi-Ethnic Study of Atherosclerosis (MESA)

Abstract

Objective: To determine the prevalence, risk factors and natural history of hiatal hernia (HH) on CT in the general population.

Materials and methods: The Multi-Ethnic Study of Atherosclerosis (MESA) acquired full-lung CT on 3200 subjects, aged 53-94 years. Three blinded observers independently determined presence/absence and type (I-IV) of HH. Associations between HH and participant characteristics were assessed via unadjusted and multivariable-adjusted relative risk regression. HH natural history was assessed compared with prior MESA CT.

Results: Excellent interobserver agreement was found for presence (κ=0.86) and type of HH (κ=0.97). Among 316 HH identified (prevalence=9.9%), 223 (71%) were type I and 93 (29%) were type III. HH prevalence increased with age, from 2.4% in 6th decade to 16.6% in 9th decade (unadjusted prevalence ratio (PR)=1.1 (95% CI 1.04 to 1.1)). HH prevalence was greater in women (12.7%) than men (7.0%) (unadjusted PR=1.8 (95% CI 1.5 to 2.3)) and associated with proton pump inhibitor use (p<0.001). In 75 participants with HH with 10-year follow-up, median HH area increased from 9.9 cm² to 17.9 cm² (p=0.02) with a higher mean body mass index (BMI) in subjects with increasing HH size compared with HH decreasing in size: mean BMI=30.2±6.2 vs 26.8±7.2 (p=0.02).

Conclusion: HH on non-contrast CT is prevalent in the general population, increasing with age, female gender and BMI. Its association with proton pump inhibitor use confirms a role in gastro-oesophageal reflux disease and HH progression is associated with increased BMI.

Trial registration number: NCT00005487.

Keywords: gastric diseases; gastroesophageal reflux disease; hiatal hernia; oesophagus-gastric junction; radiology.

Figure 1

Subject recruitment flow chart. GE, gastro-oesophageal; MESA, Multi-Ethnic Study of Atherosclerosis.

Figure 2

Non-contrast chest CT of a woman aged 84 years. (A) Axial image showing type I hiatal hernia (white arrows). (B) Coronal oblique reformation shows gastric folds extending 2.9 cm (dashed line) above the diaphragm. (C) Axial image shows maximum hiatal hernia cross-sectional area measurement (dotted line, 7.6 cm²). A, aorta; E, oesophagus; L, liver; S, stomach.

Figure 3

Examples of normal gastro-oesophageal (GE) junction and types I, III and IV hiatal hernia (HH) on non-contrast CT. (A) Non-contrast chest CT of a man aged 80 years with three reviewers reporting normal GE junction (arrow). (B) Non-contrast chest CT of a woman aged 59 years with type 1 HH (arrow) reported by one of three reviewers and considered normal by the other two reviewers. (C) Non-contrast chest CT of a man aged 85 years with two out of the three reviewers reporting type I HH (arrows). (D) Non-contrast chest CT of a man aged 64 years with all three reviewers reporting type I HH (arrows). (E) Non-contrast chest CT of a man aged 75 years with three reviewers reporting type III HH (arrows). (F) Non-contrast chest CT of a woman aged 84 years with three reviewers reporting type IV HH (solid arrow) with colon in the thorax (dashed arrow). A, aorta; H, heart; L, liver; S, stomach; Sp, spleen.

Figure 4

Non-contrast chest CT of a woman aged 70 years showing natural history of hiatal hernia (HH) over 10 years from Multi-Ethnic Study of Atherosclerosis (MESA) Exam 1 (2000–02) to MESA Exam 5 (2010–12). (A) Axial image of type III HH (arrows) at MESA Exam 1 (2001). (B) Increased size of type III HH (arrows) at MESA Exam 5 (2011). (C) Coronal reformation at MESA Exam 5 showing most of stomach herniated into thorax (arrows). A, aorta; H, heart; L, liver; S, stomach.