Hiatal Hernia Difficult to Diagnose Without Surgery

Lara C. Pullen, PhD

February 15, 2012

February 15, 2012 — High-resolution manometry has a high specificity (95.12%) as well as a high predictive value (91.6%) for type 1 sliding hiatal hernia in patients with gastroesophageal reflux disease (GERD). Although this makes the test superior to endoscopy, high-resolution manometry lacks the sensitivity (52.78%) to be the sole test used for the diagnosis of hiatal hernia in patients with GERD.

High-resolution manometry is therefore a good, but not ideal, option for patients with GERD, according to findings from a new study published online February 9 in Diseases of the Esophagus.

The study included 83 consecutive patients, 42 of whom were found to have type 1 sliding hiatal hernia (>2 cm) during surgery, the gold standard for diagnosis. The patients (61% women; mean age, 52 ± 13.2 years) underwent high-resolution manometry and endoscopy before surgery.

Y.S. Khajanchee, MD, and colleagues from the Gastrointestinal and Minimally Invasive Surgery Division, Oregon Clinic, Portland, found that 22 patients met the criteria for a hiatal hernia by high-resolution manometry, and 36 patients were diagnosed with hiatal hernia by preoperative endoscopy. The authors noted a significant discordance (P = .033) between the 2 tests.

The very high specificity of the high-resolution manometry makes it a far better test than endoscopy to rule out hiatal hernia (likelihood ratio of a positive test, 10.72 for manometry vs 1.72 for endoscopy). False-positive rates also were significantly fewer for high-resolution manometry compared with endoscopy (4.88% vs 31.71%; P = .01).

The high false-negative rates for both high-resolution manometry and endoscopy make both tests unreliable for ruling in hiatal hernia (47.62% for high-resolution manometry vs 45.62% for endoscopy; P = .62). The authors note that a negative result by either high-resolution manometry or endoscopy mandates additional testing.

Many patients with objective GERD have hiatal hernias, and the diagnosis of hiatal hernia may determine whether or not a patient receives antireflux surgery. The test for hiatal hernia is typically done with upper gastrointestinal endoscopy, barium swallow, or conventional manometry.

The authors have disclosed no relevant financial relationships.

Dis Esophagus. Published online February 9, 2012. Abstract