J Neurogastroenterol Motil  https://doi.org/10.5056/jnm18208
Morphology of the Esophageal Hiatus: Is It Different in 3 Types of Hiatus Hernias
Dushyant Kumar1, Ali Zifan1, Gary Ghahremani2, David C Kunkel1, Santiago Horgan3, and Ravinder K Mittal1*
Departments of 1Gastroenterology, 2Radiology, and 3Surgery, University of California San Diego, La Jolla, CA, USA
Correspondence to: Ravinder K Mittal, MD
University of California San Diego, Altman Clinical and Translational Research Institute Building, 9500 Gillman Drive, MC 0061, La Jolla, CA 92093-0990, USA
TEL: +1-858-543-3328, E-mail: rmittal@ucsd.edu
Received: December 18, 2018; Revised: July 4, 2019; Accepted: July 23, 2019; Published online: November 2, 2019.
© The Korean Society of Neurogastroenterology and Motility. All rights reserved.

Abstract
Background/Aims
The esophageal hiatus is formed by the right crus of the diaphragm in the majority of subjects. Contraction of the hiatus exerts a sphincter-like action on the lower esophageal sphincter (LES). The aim is to study the hiatal anatomy (using CT scan imaging) and function (using high-resolution manometry [HRM]), and esophageal motor function in patients with sliding and paraesophageal hiatal hernia.
Methods
We assessed normal subjects (n = 20), patients with sliding hernia (n = 18), paraesophageal type 2 hernia (n = 19), and paraesophageal type 3 hernia (n = 19). Hernia diagnosis was confirmed on the upper gastrointestinal series. The hiatal morphology was constructed from the CT scan images. The LES pressure and relaxation, percent peristalsis, bolus pressure, and hiatal squeeze pressure were assessed by HRM.
Results
The CT images revealed that the esophageal hiatus is formed by the right crus of the diaphragm in all normal subjects and 86% of hernia patients. The hiatus is elliptical in shape with a surface area of 1037 mm2 in normal subjects. The hiatal dimensions were larger in patients compared to normal subjects. The HRM revealed impaired LES relaxation and higher bolus pressure in patients with paraesophageal compared to the sliding hernia. The hiatal pinch on HRM was recognized in significantly higher number of patients with sliding as compared to paraesophageal hernia.
Conclusions
Using a novel approach, we provide details of the esophageal hiatus in patients with various kinds of hiatal hernia. Impaired LES relaxation in paraesophageal hernia may play a role in its pathophysiology and genesis of symptoms.
Keywords: Esophageal peristalsis; Hiatal, hernia; Lower esophageal sphincter; Manometry; Tomography X-ray computed


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