How Hiatal Hernias Are Diagnosed

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Since most hiatal hernias do not cause any symptoms, they will usually be discovered during a routine chest X-ray for an unrelated condition. At other times, a hiatal hernia may be suspected in people with severe acid reflux who fail to respond to antacids or other treatments. For such cases, there are a number of tests doctors can use to confirm the diagnosis, including X-rays and endoscopy. Esophageal manometry may also be used, but this is not common.

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Imaging

Smaller hiatal hernias are often difficult to spot on a regular X-ray and may only appear as a gas-filled structure in the chest cavity. To provide better definition, imaging tests such as an upper GI barium study or computed tomography (CT) scan may also be ordered.

Barium Study

The preferred method of diagnosis of a hiatal hernia is an upper gastrointestinal (GI) barium study. Commonly referred to as a barium swallow, the test requires you to drink roughly one-and-a-half cups of chalky fluid containing barium sulfate and, about 30 minutes later, undergo a series of X-rays. The metallic substance coats the esophagus and stomach, helping to isolate them in the imaging results. 

If you undergo this test, expect to be strapped to a table as you undergo the X-rays. During the course of the study, the table is tilted as you drink additional barium. 

While the procedure is considered safe, it can cause constipation and, in rare cases, fecal impaction. If you are unable to have a bowel movement two to three days after the procedure, call your doctor.

CT Scan

A barium study is often enough to make a definitive diagnosis. When it's unable to do so, a computed tomography (CT) scan may be ordered. This may be necessary for people who are obese or have undergone previous abdominal surgery.

A CT scan can be invaluable in an emergency situation, such as a gastric volvulus (a serious condition in which the stomach twists more than 180 degrees) or strangulation (where compression or twisting of the herniation entirely cuts off the blood supply).

Procedures and Tests

Your doctor may want a closer look to make a diagnosis, or desire additional results to help confirm one or determine the severity of your condition. In those cases, these options may be considered:

Upper GI Endoscopy

A hiatal hernia can also be diagnosed with a procedure known an upper GI endoscopy. This is a direct viewing method in which a flexible scope, called an endoscope, is inserted into your throat to get live images of the esophagus, stomach, and duodenum (the first part of the small intestines).

The procedure will require you to stop eating or drinking four to eight hours before testing. Prior to the procedure, you are given an intravenous sedative to help relax you. A numbing spray for your throat may also be used. The procedure usually takes between 10 and 20 minutes, with an additional hour needed to recover from the sedation.

Endoscopy can sometimes cause bloating, gas, cramping, and sore throat. Call your doctor if you develop a fever, chills, abdominal pain, or bleeding from the throat.

Esophageal Manometry

Esophageal manometry is a newer technology that evaluates how the muscles of the esophagus and esophageal sphincter (valve) are functioning; while a possible diagnostic test, it is not commonly done. Esophageal manometry can help your doctor identify motor dysfunctions, such as dysphagia (difficulty swallowing), and how your hernia may be contributing to them.

The procedure is performed by first anesthetizing a nostril with a numbing ointment. A thin tube, equipped with sensors, is then fed through your nostril and down to your esophagus. The digital monitor allows the technician to view and record changes in relative pressure as you swallow.

A manometry result can help your doctor determine the appropriate course of treatment. A sore throat and nose irritation are the most common side effects.

Esophageal pH Monitoring

Esophageal pH monitoring is a test used to record changes in the acidity of your esophagus over a period of time (as measured by the pH). It also involves the insertion of a tube-like sensor through the nostril which is connected to a monitor you wear on your belt. During the next 24 hours, the monitor registers every time you experience acid reflux and records the varying changes in pH levels. Again here, while a possible test for diagnosing hiatal hernia, it is not commonly used.

Classification

Once a hiatal hernia is diagnosed it is classified by type, which can help direct treatment and/or be used to monitor any changes in your condition. The types are classified by the size and characteristics of the hernia:

  • Type 1 is known as a sliding hernia; the stomach remains in its usual alignment while the herniated portion slips in and out of the hiatus (the hole in the diaphragm through which the esophagus passes).
  • Type 2 is a paraesophageal hernia, which doesn't slide in and out of the hiatus but remains relatively fixed next to the esophagus.
  • Type 3 occurs when the gastroesophageal junction (the junction between the esophagus and stomach) begins to bulge through the hiatus.
  • Type 4 occurs when the herniation allows the stomach and other organs, such as the colon or liver, to infiltrate the chest cavity.

Differential Diagnoses

Acid reflux symptoms are not uncommon in people with a hiatal hernia. Large hernias may cause other, more profound symptoms such as severe chest pain, vomiting, retching, and aspiration pneumonia (caused by coughing up food into the lungs).

Even if a hiatal hernia is confirmed, a differential diagnosis may be needed to exclude other causes, especially if the hernia is small and inconsistent with the severity of symptoms. Some of the other possible causes include:

  • Angina, which can be differentiated during a cardiac stress test
  • Pneumonia, the causes of which may be differentiated by a chest X-ray and blood tests
  • Gastroesophageal reflux disease (GERD), which can be differentiated by the chronic nature of the symptoms, as well as signs of esophageal or tooth erosion
  • Gastric outlet obstruction, which can be differentiated by impairment at the pylorus (the opening from the stomach into the duodenum) rather than the hiatus
Treatment Options for Hiatal Hernia
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