Diagnosis

Endoscopic diagnostic criteria

- Double-ring configuration with an intervening, bell-shaped dilatation. The proximal ring is formed by the lower esophageal sphincter (LES), the distal ring by the esophageal hiatus.

- The gastroesophageal boundary (Z-line) is within the dilated segment, several centimeters above the esophageal hiatus.

- Shortened distance between the Z-line and incisor teeth

- Radial folds passing into the hiatus in the lower part of the hernia

- Cardia does not close snugly around the endoscope

- Bell-shaped dilatation over the cardia

- Folds radiating into the hernia

- Ascent of the hernia during inspiration

► Caution: Do not pull the retroflexed tip into the esophagus. If this occurs, push back and then straighten the endoscope.

Differential diagnosis

► The typical appearance is unmistakable.

► Small hernias are often classified as a normal variant.

Checklist for endoscopic evaluation

► Distance of the Z-line from the incisor teeth in centimeters

► If determinable: distance of the LES from the incisor teeth in centimeters

► Distance of the esophageal hiatus from the incisor teeth

► Retroflexed view showing lack of cardial closure around the endoscope

► Evidence of reflux disease

Additional Study ► Oral contrast examination with a head-down tilt (only half of radiographically detectable sliding hernias are visible endos-copically)

Comments

Axial sliding hernia is a common finding and is frequently asymptomatic. With symptomatic reflux, initial treatment consists of supportive measures and proton pump inhibitors (PPI). If medical therapy is unsuccessful or if gastric contents are regurgitated, fundoplication should be performed.

Fig. 3.11 Axial sliding hernia a Forward view

Fig. 3.11 Axial sliding hernia a Forward view

b Retroflexed view c Very large hernia in forward view d Very large hernia in retroflexed view

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