AIM: To determine if the severity of gastroesophageal reflux disease is dependent on the size of a hiatus hernia.

METHODS: Seventy-five patients with either a small (n = 25), medium (n = 25) or large (n = 25) hiatus hernia (assessed by high resolution esophageal manometry) were investigated using 24-h esophageal monitoring and a self-assessed symptom questionnaire. The questionnaire comprised the following items, each graded from 0 to 3 according to severity: heartburn; pharyngeal burning sensation; acid regurgitation; and chest pain.

RESULTS: The percentage total reflux time was significantly longer in the group with hernia of 5 cm or more compared with the group with a hernia of < 3 cm (P < 0.002), and the group with a hernia of 3 to < 5 cm (P < 0.04). Pharyngeal burning sensation, heartburn and acid regurgitation were more common with large hernias than small hernias, but the frequency of chest pain was similar in all three hernia groups.

CONCLUSION: Patients with a large hiatus hernia are more prone to have pathological gastroesophageal reflux and to have more acid symptoms than patients with a small hiatus hernia. However, it is unlikely that patients with an absence of acid symptoms will have pathological reflux regardless of hernia size.

Most patients with pathological gastroesophageal reflux (GER) have a hiatus hernia[1]. Patients with Barrett’s esophagus that covers more than 3 cm are shown to have a hiatus hernia in 96%[2] and prolonged periods with esophageal pH < 4 in the supine position in 33%. After fundoplication for hiatus hernia, pathological GER disappears in the majority of cases[3,4]. The hernia sac is under the influence of the intrathoracic pressure in association with the intraesophageal pressure during inspiration and expiration. This leads to a significant reduction in the normal gastroesophageal pressure barrier, facilitating GER. From a mechanical point of view, the size of the hiatus and the size of the hernia sac with its rather high compliance, should reasonably be expected to have an inhibitory effect on GER and on GER symptoms. The aim of this study was therefore to determine if there is any relationship between the size of a hiatus hernia, the degree of GER, and the frequency of acid symptoms and chest pain.

Seventy-five patients were stratified into three groups with either a small (< 3 cm), a medium-sized (3 to < 5 cm), or a large (5 cm or more) hiatus hernia, assessed using high resolution manometry (HRM)[5]. They underwent 24-h esophageal pH monitoring and answered a questionnaire on the severity of heartburn, pharyngeal burning sensation, acid regurgitation, and chest pain.

The percentage total reflux time (Table 1) was significantly longer in the group with a hernia of 5 cm or more compared with the group with a hernia of < 3 cm (P < 0.002), and with the group with a hernia of 3 to < 5 cm (P < 0.04). There was no significant difference between the small- and the medium-sized groups. Pathological GER defined as > 4% total reflux time during 24-h pH monitoring was significantly more common with large hernias (64%) than with medium-sized and small hernias (24%) (Table 2). The symptom score in patients with a hernia larger than 2 cm and with pathological GER was twice that of patients with normal GER (Table 2).

Pharyngeal burning sensation, heartburn, and acid regurgitation were more common in the group with large hernias than in the group with small hernias, but the frequency of chest pain was about the same in all three hernia groups (Table 1).

Five of the patients in the group with a hernia < 3 cm had no acid or chest symptoms. Their median GER was 1.7% (range: 0.4%-3.6%). Two patients in the group with a hernia 3 to < 5 cm and no symptoms had a mean GER of 1.7% (range: 1.4%-2.0%), and two symptom-free patients in the group with a hernia 5 cm or more had a mean GER of 0.6% (range: 0.3%-0.9%).

In this study, it was found that the group with a large manometric hiatus hernia had significantly more gastroesophageal reflux and more acid symptoms than the group with small hernias. This is in agreement with the study by Ott et al[6]. They found that patients with large hiatus hernias, assessed with barium esophagogram, were more likely to have abnormal findings on pH monitoring, and that a minimal sized hiatus hernia was a poor predictor of the presence of abnormal gastroesophageal reflux. Patti et al[7], in an upper gastrointestinal series, showed that patients with a large hiatus hernia are more exposed to acid than patients with a small hiatus hernia. In the present study, acid symptomatology was not correlated with the hiatus hernia size as long as the patient did not have pathological values during the 24-h pH test. Pathological total reflux time, i.e., more than 4% during 24 h, was not seen in any of the patients without acid or chest symptoms regardless of hernia size. This implies that certain patients with a large hernia can go without symptoms and that there is no pathognomonic relationship between hernia size, symptoms and gastroesophageal reflux.

In a study by Koch et al[8], the size of the esophageal hiatus assessed during fundoplication surgery was not found to have any relationship with symptoms, number of reflux episodes, or reflux in the upright position, but to have a significant influence on GER in the supine position. In another study, the size of the esophageal hiatus measured during surgery was found to be significantly related to the amount of acid reflux. However, it is not obvious that the degree of gastroesophageal reflux is equally dependent on the size of the esophageal hiatus and the size of the hiatus hernia itself, since a narrow hiatus canal can be found in large non-reducible hiatus hernias.

In conclusion, patients with a large hiatus hernia are more prone to have pathological gastroesophageal reflux and to have more acid symptoms than patients with a small hiatus hernia. However, it is unlikely that patients with an absence of acid symptoms will have pathological reflux regardless of hernia size.