Diagnostics

Barium swallow: most sensitive test

• Assesses type and size of a hernia (including location of the stomach and the GEJ)

used to diagnose hiatal hernia and evaluate for possible complications (see “Complications” below)

• Z-line: squamocolumnar junction, which represents the transition from the squamous epithelium-lined esophageal mucosa to the columnar epithelium-lined gastric mucosa; corresponds to the GEJ

  • Types I and III: Z-line lies above the diaphragmatic hiatus

  • Types II and IV: Z-line remains undisplaced (below the diaphragmatic hiatus)

• Chest x-ray

  • Usually incidental finding

  • Types I, II, III: retrocardiac soft tissue opacity with/without an air-fluid level

  • Type IV: retrocardiac visceral gas (small bowel/colon) or soft tissue shadows (spleen/omentum)

• CT Thorax: recommended for urgent preoperative evaluation of complicated type II, III, and IV hernias

• Esophageal manometry: helps calculate the size of a sliding hiatal hernia by accurately identifying the level of the diaphragmatic hiatus

• Esophageal pH monitoring: not a diagnostic test; useful for determining the extent of gastroesophageal reflux