Clinical Utility of Endoscopy and Barium Swallow X-Ray in the Diagnosis of Sliding Hiatal Hernia in Morbidly Obese Patients: A Study Before and After Gastric Bypass

Background The main clinical consequence of sliding hiatal hernia (SHH) is gastroesophageal reflux disease (GERD). Endoscopy and barium swallow X-ray are commonly used to diagnose SHH. We aimed to assess the clinical utility of endoscopy and X-ray in the diagnosis of SHH in morbidly obese patients before and after gastric bypass (GBP). Methods Ninety-two patients underwent reflux symptoms evaluation, upper gastrointestinal endoscopy, and barium swallow X-ray before and 6 months after banded GBP. The performance of endoscopy in diagnosing SHH was assessed, taking X-ray as reference. Endoscopy and X-ray were tested as predictors of SHH with GERD. Results SHH was more prevalent when characterized by Xray than endoscopy either before (33% vs. 17%; P=0.017) or after GBP (26% vs. 7%; P=0.001). Endoscopy showed low sensitivity (<= 40%) and high specificity (>= 94%) in diagnosing SHH. Before GBP, more patients with SHH had GERD compared to patients without SHH using either Xray (83% vs. 58%; P=0.016) or endoscopy (94% vs. 61%; P=0.009). After GBP, only patients with radiologic evidence of SHH showed higher prevalence of GERD compared to patients without SHH (50% vs. 26%; P=0.037). SHH patients also reported weekly or daily vomit more often than patients without SHH (59% vs. 32%; P=0.026). Conclusions In morbidly obese patients, X-ray is superior to endoscopy in diagnosing SHH either before or after banded GBP. In patients treated with this technique, the utilization of X-ray may help in the management of reflux symptoms and frequent vomit.