Sliding Hiatal Hernia.

Esophageal mucosa in the foreground, gastric mucosa in
the background.

A hiatal hernia occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus. Although the existence of hiatal hernia has been described in earlier medical literature, it has come under close scrutiny only in the last century or so because of its association with gastroesophageal reflux disease (GERD) and its complications. By far, the majority of hiatal hernias are asymptomatic and are discovered incidentally. On rare occasion, a life-threatening complication, such as gastric volvulus or strangulation, may present acutely.

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All endoscopic images shown in this Atlas contain video clip

Hiatus Hernia with Schatzki Ring.

40 year-old female with intermittent dysphagia to solids.

Esophageal rings were described by Schatzki as mucosal structures at the gastroesophageal junction that are smooth, thin (<4 mm in axial length), and covered with squamous mucosa above and columnar epithelium below.

Video Endoscopic Sequence  1 of 2.

Superior Esophagic Sphincter.

The video clip displays a complete retroflexed maneuver from the cardias to the upper esophagic sphincter, the video clip also shows a big hiatal hernia with reflux esophagitis.

An endoscopist must be sure to diagnose a hiatal hernia in the absence of vomiting and coughs, because it may give a false positive diagnosis of hiatal hernia.

Video Endoscopic Sequence 2 of 2.

 Hiatal Hernia retroflexed view.

The video clip shows a retroflexed endoscopic maneuver
all the way until the upper esophagic sphincter.

Video Endoscopic Sequence 2 of 3.

Hiatus Hernia

The esophagus passes through the diaphragmatic hiatus in the crural part of the diaphragm to reach the stomach. The diaphragmatic hiatus itself is approximately 2 cm in length and chiefly consists of musculotendinous slips of the right and left diaphragmatic crura arising from either side of the spine and passing around the esophagus before inserting into the central tendon of the diaphragm.

The size of the hiatus is not fixed, but narrows whenever intra-abdominal pressure rises, such as when lifting weights or coughing.

Video Endoscopic Sequence  3 of 3.

Endoscopic Image of a Hiatus Hernia.

Video Endoscopic Sequence  1 of 2.

Lower Esophageal (Schatzki) Ring with esophageal varices and reflux esophagitis.

A 59 year-old male with esophageal reflux disease presenting with episodes of cough and chest pain. 14 years ago, underwent a splecnectomy.

Video Endoscopic Sequence  2 of 2.

The image and the video display a retroflexed maneuver the Schatzki ring is appreciated with some varices.

Video Endoscopic Sequence 1 of 3.

Esophagus Schatzki Ring.

A typical appearing uniform and weblike Schatzki mucosal ring.
The cause of lower esophageal rings is still a matter of debate.

Video Endoscopic Sequence 2 of 3.

Schatzki Ring retroflexed view.

Lower Esophageal (Schatzki) Ring.

Retroflexed endoscopic view of a Schatzki ring. Schatzki rings are almost invariably seen in association with hiatal hernia, as is the case here. The inner ring diameter of a Schatzki ring is an important determinant of whether the ring is associated with dysphagia. The ring diameter can be estimated when viewed from the retroflexed position by referencing the ring to the known diameter of the endoscope.

The lower esophageal ring, also known as a Schatzki or mucosal Bring, is located at the squamocolumnar junction with a hiatal hernia. This is a thin mucosal membrane or diaphragm-like ring usually no more than 2-3 mm thick.

Video Endoscopic Sequence 3 of 3.

Lower Esophageal (Schatzki) Ring.

With symptomatic Schatzki ring had the evidence of significant gastroesophageal reflux either on endoscopy or ambulatory 24-h esophageal ph monitoring. 

Pathophysiology: The pathogenesis of Schatzki rings is not clear, and at least 4 hypotheses have been proposed. These hypotheses may not be mutually exclusive. Proposed hypotheses are as follows:
1. The ring is a pleat of redundant mucosa that forms when the esophagus shortens transiently or permanently for unknown reasons. 
2 The ring is congenital in origin.
3.The ring is actually a short peptic stricture occurring as a consequence of gastroesophageal reflux disease.
4.The ring is a consequence of pill-induced esophagitis.




 

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Video Endoscopic Sequence 1 of 3.

Esophageal Varices and Hiatus Hernia

This 93 year-old male in a routine endoscopy was found that have both clinical entities.

Video Endoscopic Sequence 3 of 3.

Aside from de hiatus hernia the patient presents with esofageal varices

No clear correlation exists between the size of a hiatal hernia and the severity of the symptoms. A very large hiatal hernia ay be present with no symptoms at all. Some complications are specific for a hiatal hernia.

Esophageal complications By far, the majority of hiatal hernias are asymptomatic. Often, patients are left with the impression that they have a disease when a hiatal hernia is diagnosed.

In rare cases, however, a hiatal hernia may be responsible for intermittent bleeding from associated esophagitis, erosions (Cameron ulcers), or a discrete esophageal ulcer, leading to iron-deficiency anemia.

The prevalence of large hernias in patients with iron deficiency anemia is 6-7%. This particular complication is more likely in patients who are bed-bound or those who take nonsteroidal anti-inflammatory drugs. Massive bleeding is rare.