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.

 For further endoscopic information, download the video clip
 by clicking on the endoscopic image. Wait to be
 downloaded complete then Press Alt and Enter for full
 screen ( Windows Media), Real Player: Ctrl and 3. All
 endoscopic images shown in this Atlas contain video clips.

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 1 of 3.

Hiatus Hernia

 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 scrutiny
 only in the last century or so because of its association with
 gastroesophageal reflux disease (GERD) and its
 complications. By far, most hiatal hernias are
 asymptomatic and are discovered incidentally. On rare
 occasion, a life-threatening complication, such as gastric
 volvulus or strangulation, may present acutely.

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.

Hiatus Hernia

Hiatus Hernia with Schatzki Ring.

 A 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 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.

 



                                          Medline.

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.

                                                  
                                          Medline.
 

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.

                                          
                                         Medline.   

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.

 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 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 2 of 3.

 Hiatal hernias are relatively common and, in themselves,
 do not cause symptoms. For this reason, most people with
 hiatal hernias are asymptomatic. Hiatal hernias may
 predispose to reflux or worsen existing reflux in a minority
 of individuals. Physicians should resist the temptation to
 label hiatal hernia as a disease.

 Patients can have reflux without a demonstrable hiatal
 hernia. When a hernia is present in a patient with
 symptomatic GERD, the hernia may worsen symptoms for
 several reasons, including the hiatal hernia acting as a
 fluid trap for gastric reflux and increasing the acid contact
 time in the esophagus. In addition, with a hiatal hernia,
 episodes of transient relaxation of the LES are more
 frequent and the length of the high-pressure zone is
 reduced. The main symptoms of a sliding hiatal hernia are
 those associated with reflux and its complications.

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 may 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
 hiatal 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.

•  Nonesophageal complications

 Incarceration of a hiatal hernia is rare and is observed only
 with paraesophageal hernia.

 When this occurs, it can present abruptly, with a sudden
 onset of vomiting and pain, sometimes requiring immediate
 operative intervention.