Prevalence of Hiatus Hernia in Patients with Gastro Esophageal Reflux Disease Attending Endoscopy Unit View PDF

GERD is believed to occur when there is an imbalance between defensive factors and aggressive factors affecting the lower esophagus sphincter (LES). Defensive factors are gastroesophageal junction (GEJ), esophageal acid clearance and tissue resistance. Aggressive factors are gastric factors such as gastric acid secretion and delayed gastric emptying [1]. The GEJ is the first and primary line of esophageal defense against damage by refluxate, and pathological reflux is thought to occur when there is impairment in this barrier. GEJ is an anatomically complex region that consists of the intrinsic LES, the crural diaphragm, the intra-abdominal location of the LES, the acute angle of His and the phreno-esophageal ligament/membrane [2]. LES is the distal 3 - 4 cm segment of the esophagus that is tonically contracted at rest and is the principal component of the anti-reflux barrier. Normal resting LES pressure varies from 10 - 45 mm Hg relative to the intra gastric pressure, and there is a considerable temporal variation in the basal LES tone with it being lowest after meals and highest at night [1]. Tone of LES is maintained by the intrinsic tone of the muscle itself and by the extrinsic cholinergic innervation. The LES tone is also influenced by many factors such as intra-abdominal pressure, circulating peptides and hormones, foods and many drugs. Progesterone, fatty meal, chocolate, alcohol, peppermint, theophylline, octreotide, and anticholinergics are known to decrease the LES tone [3, 4]. Hiatal hernia is a condition in which parts of the abdominal contents, mainly the GEJ and the stomach, are proximally displaced above the diaphragm through the esophageal hiatus into the mediastinum [4]. Esophageal hiatus is an elliptically shaped opening most commonly formed by elements of the right diaphragmatic crus that encircle the distal portion of the esophagus in a sling-like fashion. Normally, the distal portion of the esophagus is anchored to the esophageal hiatus by the phreno-esophageal ligament/membrane (also called the fascia of Laimer) that is formed by the fusion of intrathoracic and Intraabdominal fascia. The phreno-esophageal ligament/membrane is inserted circumferentially into the esophageal musculature in the close vicinity of the squamous columnar junction. This ligament/membrane is essential in maintaining the competence of GEJ and preventing the migration of GEJ and/or stomach into the posterior mediastinum by sealing off potential spaces between the esophageal hiatus and the distal portion of the esophagus [5, 6]. The use of endoscopy has become widespread over the past few decades and is now considered the standard modality for diagnosing and treating diseases of the upper gastrointestinal tract. Although barium contrast study has been the most commonly applied method for diagnosing hiatal hernia worldwide, hiatal hernia is increasingly diagnosed with endoscopy [7-9]. The most commonly accepted diagnostic criterion of endoscopic hiatal hernia is the proximal dislocation of GEJ of >2 cm above the diaphragmatic indentation. Many studies have demonstrated that hiatal hernia is closely related to reflux symptoms, reflux esophagitis, Barrett’s esophagus and esophageal adenocarcinoma. These above-mentioned associations between hiatal hernia and reflux symptoms, reflux esophagitis, Barrett’s esophagus and esophageal adenocarcinoma are largely due to the disruption of many of the anti-reflux mechanisms that lead to increased esophageal acid exposure [10]. These impairments can largely be divided into incompetence of GEJ [11, 12] relationship with LES [13] and compromise of esophageal acid clearance [14, 15]. The aims of the study are to determine the prevalence of hiatus hernia in patients with GERD attending endoscopy unit at Al Sadr Teaching Hospital in Basra city, Iraq and to describe the role of H. pylori infection in the development of hiatus hernia.