Preoperative diagnosis of hiatal hernia: barium swallow X-ray, high-resolution manometry, or endoscopy?

Background: The assessment of hiatal hernias (HH) is typically done with barium swallow X‑ray, upper endoscopy, and by high-resolution esophageal manometry (HRM). The aim of this study was to assess the clinical utility of these methods in terms of HH detection and their correlation to gastroesophageal reflux disease (GERD).

Methods: A retrospective comparative analysis of patients with symptoms of GERD was carried out. The performance of endoscopy and HRM in diagnosing HH was assessed, taking barium swallow X‑ray as a reference. Furthermore, statistically comparative analysis between detected hernias and the presence of reflux disease in ambulatory impedance-pH monitoring (MII) was performed.

Results: Overall, 112 patients were analyzed. Barium swallow X‑ray showed no correlation either to HR manometrically or to endoscopically assessed HH. Significant accordance in the detection rate of HH was proved between HRM and gastroesophagoscopy ( p  < 0.001). Only endoscopically assessed HH showed a significant correlation with GERD ( p  = 0.047). No correlation between detected hernias and GERD could be found either with HRM or with barium swallow X‑ray.

Conclusions: Barium swallow X‑ray provided the highest rate of HH detection (76.8%). For the reliable exclusion of HH prior to treatment, all three mentioned investigations appear to be necessary in order of low conformity.