Hi Ali,

the discomfort is probably due to the fact that the hiatal hernia, almost inevitably associated with reduced cardia's continence, results in a more frequent emission of air during endoscopy

Dear Paolo,

Tnx for your attention. Air emission seems to have some effects. What is your opinion on esophageal hypersensitivity as a result of reflux esophagitis which is more frequent with hiatal hernia?

Dear Ali

I personally did feel that endoscopy in patients having large sized sliding hiatal hernias is usually a little bit disturbing both me as an endoscopist and the patient. I had not seen any evidence between this linkage.

As Paolo has said, I always thought that the underlying mechanism should be the incompetence of the LES. As a result these patients do belch significantly more than others. It appears that they cannot tolerate air insufflation into stomach.

Distal esophageal hypersensitivity that you mention, should be present in these patients, but it would be to acidic or spicy food not air in the stomach.

If you publish your research anywhere let me know to read it through.

Dear Iradj,

Many thanks for your attention. Sure.

Hi Ali,

Interesting finding that hiatal hernia (HH) patients should suffer more from an upper GI endoscopy. Empirically, that is not a very obvious observation, at least not from my personal experience of thousands of HH investigations since the early 1990s. It would be interesting to see the evidence behind your conclusion. Is it published?

I´d like to elaborate on the reply from Paolo above:

As I also have had 3 upper GI endoscopy for my own HH, I can inform you that although the difficulty to hold the inflated air ("frequent emission of air") may be irritating for the examiner, it is not discomforting but in fact a relief for the patient to get rid of it!

It is indeed more difficult to examine a patient with a poor valve mechanism in the cardia complex, due to the constant loss of air. Especially for a less experienced endoscopist, that can be a very significant complexity factor. Could it be that the higher degree of difficulty for the examiner, renders endoscopies to be more painful for HH patients?

Dear Ali

I think your observation is correct and that patients with a good cardia's continence show more tolerance during endoscopic examination even when their stomachs are completely filled with air. Obviously other factors are envolved, such as lingual and hypopharyngeal hypersensitivity, anxiety, overweight (greater difficulty in breathing), etc..

About the esophageal hypersensitivity, I do not think that it has a role in discomfort; have you tried to see if patients with esophagitis, with or without hiatal hernia, have more discomfort than those without esophagitis?

Paolo,

Because it was an accidental finding, we did not record such data precisely for our study and re-evaluation of patients documents is somehow not easily possible. For example, we did not evaluate patients BMI which as you mentioned might have a role. I hope we could assess this association more precisely in future as it could be a predictor of need for additional IV sedation.

Dear Bengt,

Thanks for your response. The endoscopist was one of my experienced professors, so endoscopist experience could not be an important reason in this case. I'll discuss your suggestion with him to see what is his view.

Regarding the report, we have submitted the manuscript just recently to AP&T.

in the study who you recently published the execution time of gastroscopy was detected? In the group with hiatal hernia in fact, may be included patients with massive hernias that make long and difficult the exam. In my opinion the extended time may readily explain the increased discomfort reported by the patients.

Dear Vittorio,

Thanks for your response.

Duration of EGD was about 20 seconds longer in those with hiatal hernia (total sample size = 220, P = 0.076). However, it should be noted that this 20-second longer duration might be due to more discomfort and less tolerance associated with hiatal hernia (by other mechanisms) and not directly because of longer examination.

I have 25 years experience in endoscopy and my opinion is that cardias incompetence and younger age together with anxiety related reflux-like functional dyspepsia rather than hiatal hernia size itself play a major role in making the patient belch during gastroscopy. The latter by itself is more likely to make accurate endoscopic view of the stomach more difficult to obtain than being a direct cause of increased patient discomfort. However, as you need on average longer time to accurately 'scope the stomach if air is repetedly expelled, prolonged examination time may be the explanation of worse tolerance, particularly in younger patients who are more reactive to visceral stimuli. I am curious to see whether in your study HH remains an independent factor for reduced tolerance after correction for age, reflux-like dyspepsia and exam duration.

Dear Giovanni,

Tnx for your attention.

We did a multivariate regression analysis with controlling age, gender, pre-EGD anxiety, drug or placebo administration, and having HH as possible independent factors and pain/discomfort as dependent factor. Independent factors found to be pre-EGD anxiety and HH. When I added endoscopy duration to the model, the association between HH and pain/discomfort still existed.

Anxiety and HH also independently predicted the need for additional IV sedation; IV sedation was needed in less than 10% of those without HH but in more than 60% of those with HH. It seems that HH plays especial role in this regard. The association between HH and pain/discomfort seems to be out of bias; however, the association between HH and more need for IV sedation might be affected partially by the decision of the endoscopist who properly has had hypothesized that those with HH are less tolerable and need more IV sedation.

Dear Ali

We often see hiatal hernias in our practice. According to our observations, the minimum sliding hernia of 1st degree & when the hiatus is lowest extended, gives a fairly expressed pain deep in the left upper quadrant, which is not associated with other problems and is often much stronger than in hernias with larger diameter. This pain bothering the patient regularly and is the main complaint.

Thus, in this situation the basis of pain is the mechanical strangulation (jamming) of stomach area in the hiatus, usually it is a part of cardia and surrounding area ot stomach fundus.

If we have a larger diameter of the hiatus, it is no jamming and the pain is considerably less.

In hiatal hernias diagnostics we Prefer EGDS without any sedation because diagnostic value of this procedure is significantly higher, in our opinion: sliding hernia manifested mostly.

Thank you.

Have you noticed any connection between the pain severity and nutritional status of the patient?

According to our observations, there is some relationship between nutritional status and pain. Again - in the case of excessive body weight patient usually has a significantly extended hiatus, and jamming effect is minimal. Therefore, there is still more painfully for patients with minimal nutritional status - deep in the left upper quadrant.

PS: the diagnosis is always supplement the X-ray examination with specific tests. But that's another story)))

PPS: soon we will begin researching this problem in our clinic, for a start.

Sorry that its late but for those who are interested we published the results here:

http://www.ncbi.nlm.nih.gov/pubmed/24977401