High resolution manometry (HRM) is the most accurate non-invasive test for diagnosing sliding hiatal hernia. HRM can classify hiatal hernias as no hernia, small (1-2 cm separation), or large (>2 cm separation) based on the distance between the lower esophageal sphincter and crural diaphragm pressure zones. A study found HRM had 94% sensitivity and 91% specificity for diagnosing hiatal hernia compared to open surgical assessment, outperforming barium swallow radiography and upper endoscopy. HRM is concluded to be the best test for accurately diagnosing and classifying the size of sliding hiatal hernias.

1. Diagnosis of sliding hiatal hernia
Samir Haffar MD
Assistant professor of gastroenterology

2. Diagnosis of sliding hiatal hernia
① Types of hiatal hernia
② Barium swallow radiography
③ Upper gastrointestinal endoscopy
④ Standard esophageal manometry
⑤ High resolution manometry (HRM)

3. ① Types of hiatal hernia

4. Type of hiatal hernia
Normal anatomy Type I Type II Type III
sliding hiatal hernia paraesophageal hernia mixed hiatal hernia
most common (95%)
Duranceau A. Dis Esophagus 2016;29(4):350–66.

5. Normal anatomy
Ishimura N et al. Dig Endoscopy 2009;21:213–218.
Distance between squamous-columnar junction
and diaphragmatic indentation < 2 cm

6. Hiatal hernia type 1
sliding hiatal hernia
most common form (95%)
Duranceau A. Dis Esophagus 2016;29(4):350–66.
Distance between squamous-columnar junction
and diaphragmatic indentation > 2 cm

7. Endoscope emerges from gastroesophageal junction
which is in normal position
The endoscope retroflexes and looks at stomach fundus
herniated through diaphragm
Duranceau A. Dis Esophagus 2016;29(4):350–66.
Hiatal hernia type 2
para-esophageal hiatal hernia

8. Duranceau A. Dis Esophagus 2016;29(4):350–66.
Forward view of massive herniation observed from
gastroesophageal junction at 30 cm from incisors
Retroflexed view under the diaphragm of a type III hernia
and an enlarged hiatus
Hiatal hernia type 3
mixed hiatal hernia
Forward view Retroflexed view

9. ② Barium swallow radiography

10. Kahrilas PJ et al. Best Practice Research Clin Gastroenterol 2008;22(4):601–616.
Anatomical features of sliding hiatal hernia
viewed radiographically
Ring A: Superior margin of LES (highest pressure zone in LES)
Ring B: At squamocolumnar junction, present in 15% of persons
Division of phrenic ampulla into oesophageal vestibule (A
to B ring) & HH (B ring to sub-diaphragmatic stomach)
Hiatal hernia: Distance from B ring to hiatus > 2 cm

11. Barium swallow radiography
Kahrilas PJ et al. Best Practice Research Clin Gastroenterol 2008;22(4):601–616.
Well developed ring A and ring B
Hiatal hernia defined by distance from B ring to hiatus > 2 cm
Image in early swallow: hiatus hernia indicated by black bracket
Image in late swallow: hiatus hernia indicated by white bracket
Size estimate of hiatal hernia depends on when in the swallow
sequence the measurement is made
Early swallow Late swallow

12. Limitations of barium swallow radiography
• Not all of previous structures always demonstrable radiographically
• Commonly, A ring but not B ring is evident and thus the limits
of measurement defining hiatus hernia become arbitrary
• B ring located at SCJ only demonstrable in only 15% of individuals
• Measurement of B ring to hiatus depends on timing of swallow:
early swallow, late swallow or between swallows
• Frequency of sliding hiatus hernia increased in case of abdominal
compression during barium swallow imaging
Prevalence of sliding hiatal hernia vary enormously from 10 – 80%
Identification of type 1 hernia < 3 cm by radiography is unreliable
Kahrilas PJ et al. Best Practice Research Clin Gastroenterol 2008;22(4):601–616.

13. Hyun JJ et al. Gut and Liver 2011;5(3):267–277.
Barium swallow radiography
When sliding hiatal hernia is > 3 cm, is its
presence obvious because gastric folds are
evident traversing diaphragm both during
swallow-induced shortening & at rest
diaphragmatic
indentation
diaphragmatic
indentation

14. ③ Upper gastrointestinal endoscopy

15. Upper gastrointestinal endoscopy
forward view
Sliding hiatus hernia diagnosed when
distance between squamocolumnar junction
and diaphragmatic impression > 2 cm
Accuracy and reproducibility of such
measurements have not been tested
Kahrilas PJ et al. Best Practice Research Clin Gastroenterol 2008;22(4):601–616.

16. Kahrilas PJ et al. Best Practice Research Clin Gastroenterol 2008;22(4):601–616.
Gastro-esophageal area open all the time
Squamous epithelium of distal esophagus seen from retroflexed view
Sliding hiatal hernia is always present with this deformity
Upper gastrointestinal endoscopy
retroflexed view

17. Limitations of upper gastrointestinal endoscopy
• Extremely patulous hiatus:
Difficulty to precisely localize the crural diaphragm
• Excess insufflation of stomach
Might exaggerate the apparent size of hernia
• Barrett’s metaplasia:
Difficulty to ascertain location of native squamocolumnar junction
HH: hiatal hernia
Kahrilas PJ et al. Best Practice Research Clin Gastroenterol 2008;22(4):601–616.
Little study of sensitivity of endoscopic measurement of sliding HH
Endoscopy suffers from similar limitations to barium swallow
Identification of type I hernia < 3 cm with endoscopy is unreliable

18. ④ Standard esophageal manometry

19. Standard esophageal manometry in hiatal hernia
one circumferential sensor distally & pulled out by 0.5 cm steps
Fornari F et al. Dig Liver Dis 2009;41:886–890.
Dual high-pressure zones at gastro-esophageal junction
Distal hump corresponds to diaphragmatic crura
Proximal hump corresponds to lower esophageal sphincter

20. Fornari F et al. Dig Liver Dis 2009;41:886–890.
Diagnostic accuracy of conventional manometry
Endoscopy as the referential technique
Percentage 95% confidence interval
Sensibility 28% 19 – 40
Specificity 97% 93 – 99
Positive predictive value 82% 63 – 92
Negative predictive value 76% 73 – 79
Study of 215 consecutive patients with or without HH

21. ⑤ High resolution manometry

22. Normal HRM following a wet swallow
EGJ: esophago-gastric junction – LES: lower esophageal junction
Conklin JL. J Neurogastroenterol Motil 2013;19(3):281–294.
UES: Upper esophageal sphincter
S1: Striated esophageal muscle
TZ: Transition zone from striated to smooth muscle
S2: Proximal esophageal smooth muscle
S3: Distal esophageal smooth muscle
S4: LES repositioning itself at its resting position
EGJ: Esophago-gastric junction
Composed of tonic LES contraction & phasic
crural diaphragm contraction with inspiration

23. • Thoracic cavity: Pressure decreases during inspiration
Pressure increases during expiration
• Abdominal cavity: Pressure increases during inspiration
Pressure decreases during expiration
• Pressure inversion point: Point at which pressure across EGJ during
“PIP” inspiration becomes negative
Indicates location of crural diaphragm
Esophago-gastric junction
Composed of tonic LES contraction and cyclic crural contraction
Conklin JL. J Neurogastroenterol Motil 2013;19(3):281–294.

24. Esophago-gastric junction in HRM
• Type I: no separation between LES & CD (normal)
• Type II: 1 – 2 cm separation (small hiatal hernia)
• Type III: > 2 cm of separation (large hiatal hernia)
Distance between maximal LES pressure & maximal CD pressure
CD: crural diaphragm – HRM: high resolution manometry – LES: lower esophageal sphincter
Tolone S et al. United Eur Gastroenterol J 2018;6(7)981–989.

25. Esophago-gastric junction type I
E: expiration – EGJ: esophago-gastric junction – I: inspiration – LES: lower esophageal junction
Conklin JL. J Neurogastroenterol Motil 2013;19(3):281–294.
** tonic LES contraction
* cyclic crural contraction with respiration
red arrowhead: location of pressure inversion point (PIP)
EGJ type 1: normal
coincident LES and crural diaphragm
distancefromnares(cm)
I E

26. Esophago-gastric junction type II
E: expiration – EGJ: esophago-gastric junction – I: inspiration – LES: lower esophageal junction
Conklin JL. J Neurogastroenterol Motil 2013;19(3):281–294.
** tonic LES contraction
* cyclic crural contraction with respiration
red arrowhead: location of pressure inversion point (PIP)
EGJ type 2: small sliding hiatal hernia
LES-crural diaphragm separation 1-2 cm
distancefromnares(cm)

27. E: expiration – EGJ: esophago-gastric junction – I: inspiration – LES: lower esophageal junction
Conklin JL. J Neurogastroenterol Motil 2013;19(3):281–294.
Esophago-gastric junction type III
** tonic LES contraction
* cyclic crural contraction with respiration
red arrowhead: location of pressure inversion point (PIP)
EGJ type 3: large sliding hiatal hernia
LES-crural diaphragm separation > 2 cm
distancefromnares(cm)
I E

28. Types of esophageal-gastric junction
Distance between maximal LES pressure & maximal CD pressure
CD: crural diaphragm – HRM: high resolution manometry – LES: lower esophageal sphincter
Tolone S et al. United Eur Gastroenterol J 2018;6(7)981–989.
Type I Type II Type III
Coincident LES & CD
normal
1 – 2 cm separation
small hiatal hernia
> 2 cm separation
large hiatal hernia

29. Large sliding hiatal hernia
Three high pressure zones: UES, LES and crural diaphragm
Swallow followed by propagated contraction along esophagus
LES & crural diaphragm separated by more than 2 cm
LES: lower esophageal sphincter – UES: upper esophageal sphincter
Roman S et al. BMJ 2014;349:g6154.

30. Diagnostic accuracy of radiography, endoscopy and HRM
Open surgical assessment as gold standard
AUROC: area under receiver operating characteristic – HRM : high resolution manometry
Tolone S et al. United Eur Gastroenterol J 2018;6(7)981–989.
Study of 100 consecutive patients
Radiography Gastroscopy HRM
Sensibility 70% 96% 94%
Specificity 98% 74% 91%
Positive predictive value 97% 81% 93%
Negative predictive value 74% 95% 93%
Kappa value 0.66 0.72 0.85
AUROC – – 0.929

31. Conclusion
• HRM can accurately diagnose sliding hiatal hernia with
high sensibility and specificity
• HRM seems to classify sliding hiatal hernia (no hiatal hernia,
small or large size) better than radiography and endoscopy
• HRM reaches optimal agreement w open surgical assessment
HRM: high resolution manometry

32. Thank You