Endoscopic measurement of cardia circumference as an indicator of GERD

Association of gastroesophageal junction laxity and gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease is a prevalent condition with significant clinical variability, complicating its evaluation and treatment. The gastroesophageal flap valve is a fundamental evaluation method, but have shown limitations in specificity and reliance on subjective endoscopists' experience. Recent insights suggest that gastroesophageal junction laxity may offer an objective and quantifiable measurement for the presence of gastroesophageal reflux disease.

METHODS

This retrospective study analyzed data from 401 patients who underwent comprehensive evaluations, including a symptom questionnaire, endoscopy, pH-impedance monitoring, high-resolution manometry, and treatment directions, between January 1, 2022 and October 31, 2023. Gastroesophageal junction laxity was assessed using a modified approach based on endoscopic image analysis, with the diameter of endoscope as reference to estimate the long diameter of the laxity ring. The independent association of gastroesophageal junction laxity with pathologic acid exposure, esophagitis, and hiatal hernia were assessed by adjusting with age and sex.

RESULTS

The mean age was 44.5 ± 5.5 years old, and 49.9% (200/401) were male. The most common symptoms (≥ 1 point) were acid regurgitation (333/401, 83.0%), heartburn (315/401, 78.6%), belching (278/401, 69.3%), bloating (241/401, 60.1%), and globus sensation (241/401, 60.1%). The gastroesophageal junction laxity was significantly associated with pathologic acid exposure, esophagitis, hiatal hernia, and lower esophageal sphincter resting pressure. Notably, with the increase in gastroesophageal junction laxity, the rates of pathologic acid exposure, esophagitis, and hiatal hernia increased gradually, the lower esophageal sphincter resting pressure decreased gradually. The gastroesophageal junction laxity was independent associated with pathologic acid exposure (OR = 2.33, 95%CI 1.77-3.07, p < 0.001), esophagitis (OR = 2.10, 95%CI 1.62-2.73, p < 0.001), and hiatal hernia (high-resolution manometry: OR = 3.39, 95%CI: 2.46-4.67, p < 0.001) (endoscopy: OR = 21.65, 95%CI 11.70-40.06, p < 0.001).

CONCLUSION

The gastroesophageal junction laxity was significantly associated with the indicators of pathophysiology in gastroesophageal reflux disease.

Cardia Laxity under Retroflexed Endoscopy Is a Reflection of Esophageal Hiatus Enlargement

Methods

Information from patients who underwent endoscopy and CT scan in our department was collected and analyzed retrospectively. Three-dimensional reconstruction of hiatus from CT images was performed using 3DSlicer software, and the degree of esophageal hiatus enlargement was compared with the degree of gastroesophageal laxity under retroflexed endoscopy.

Results

Information from 104 patients was included for analysis. The Spearman correlation coefficient was 0.617 (p ≤ 0.001). When subgroup correlation analysis was performed according to the presence of hiatal hernia on CT, the Spearman correlation coefficient was 0.816 (p ≤ 0.001) in the hernia group and 0.351 (p = 0.002) in the nonhernia group. The proportion of hiatal hernia and severe esophagitis was increasing gradually with the degree of gastroesophageal laxity.

Conclusion

The degree of gastroesophageal laxity (cardia or hiatus) under retroflexed endoscopy reflects the degree of esophageal hiatus enlargement; with the degree of gastroesophageal laxity increasing, the proportion of HH and severe esophagitis increases gradually. This may be useful for physicians in China to guide themselves in the selection of patients for endoscopic antireflux treatment.

A novel endoscopic assessment of the gastroesophageal junction for the prediction of gastroesophageal reflux disease: a pilot study

Background and aim  Hiatal hernia and lower esophageal sphincter (LES) dysfunction play major roles in gastroesophageal reflux disease (GERD) pathogenesis. We developed a novel endoscopic assessment to evaluate the gastroesophageal junction (GEJ). This study aims to evaluate the feasibility of this method for the diagnostic prediction of GERD. Methods  A retrospective analysis of patients with GERD symptoms who underwent gastroscopy and esophageal pH-impedance monitoring was conducted. The novel assessment evaluated the following in retroflex view: 1) Cardiac Opening (CO): diameter of the opening of the cardia, 2) Sliding Hernia (SH): length from the diaphragmatic crus to the squamocolumnar junction, 3) Scope Holding Time% (SHT%): the percentage of time that the Scope Holding Sign (SHS) was observed out of 30 seconds. The SHS is defined as the lower esophagus holding the endoscope under excessive insufflation. The results of this assessment and that of pH-impedance monitoring were compared. Results  In total, 61 patients (mean age ± SD, 54.1 ± 16.4 years, 32 males) were enrolled. CO and SH were significantly correlated with acid exposure time (AET) (ρ = 0.36, P  = 0.005, and ρ = 0.36, P  = 0.004). The optimal cutoff of CO for AET > 6 % was 3 cm (Sensitivity = 72.4 %, Specificity = 46.9 %, AUC = 0.64) and that of SH was 2 cm (Sensitivity = 55.2 %, Specificity = 75.0 %, AUC = 0.70). When the population was stratified according to this cutoff, patients with CO > 3 cm and those with SH > 2 cm presented higher AET (15.1 vs 4.1 %, P  = 0.037, and 23.0 vs 3.6 %, P  = 0.026). Optimal cutoff of SHT% for the number of all reflux episodes > 80 was 75 % (Sensitivity = 81.8 %, Specificity = 54.6%, AUC = 0.67). Patients with SHT% < 75 % presented a higher number of all reflux episodes (88 vs 65, P  = 0.014). Sensitivity, specificity, and accuracy of SHT% < 75 % for all reflux episodes > 80 were 81.8 % (95 %CI: 67.7 - 91.8), 54.5% (95 %CI: 40.4 - 64.5), and 68.2 % (95 %CI: 54.0 - 78.1). Conclusion  This novel endoscopic assessment of GEJ significantly predicted the presence of GERD and merits further testing in future studies.

Hiatus Hernia as a Cause of Dysphagia

PURPOSE OF REVIEW

This review aims to discuss the putative relationship between hiatus hernia and dysphagia.

RECENT FINDINGS

Proposed mechanisms of dysphagia in patients with hiatus hernia are usually difficult to identify, but recent advances in technology (high-resolution manometry with or without concomitant impedance, ambulatory pH with impedance, videofluoroscopy, and the endoluminal functional lumen imaging probe (EndoFLIP)) and methodology (inclusion of swallows of various consistencies and volumes or shifting position during the manometry protocol) can help induce symptoms and identify the underlying disorder. Chronic reflux disease is often associated with hiatus hernia and is the most common underlying etiology. Dysmotility because of impaired contractility and vigor can occur as a consequence of repeated acid exposure from the acid pocket within the hernia, and the resultant poor clearance subsequently worsens this insult. As such, dysphagia appears to be more common with increasing hiatus hernia size. Furthermore, mucosal inflammation can lead to fibrotic stricture formation and in turn obstruction. On the other hand, there appears to be a difference in the pathophysiology of smaller sliding hernias, in that those with dysphagia are more likely to have extrinsic compression at the crural diaphragm as compared to those with reflux symptoms only. Sliding hiatus hernia, especially when small, does not commonly lead to dysmotility and dysphagia; however, in those patients with symptoms, the underlying etiology can be sought with new technologies and, in particular, the reproduction of normal eating and drinking during testing.

What is the role of radiological testing of lower esophageal sphincter function?

Radiological fluoroscopic evaluation remains the primary imaging modality of choice to evaluate patients with swallowing disorders, despite the increasing availability and technical advantages of nonradiological techniques and the current radiological focus on cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging. The radiological swallowing evaluation should be tailored to assess the entire upper gastrointestinal tract, including the lower esophageal sphincter. Fluoroscopy enables the simultaneous assessment of esophageal motility disorders, as well as structural pathologies, including strictures, webs, rings, diverticula, and tumors. Mono- and double-contrast esophagrams and solid bolus tests together allow assessment of lower esophageal sphincter function and complement other methods, such as endoscopy, manometry, or impedance planimetry. Here we review the role of radiological studies for correct assessment of structural and functional pathologies at the level of the lower esophageal sphincter.

Radiologic and endoscopic characteristics of laparoscopic antireflux wrap: correlation with outcome

After antireflux surgery for gastroesophageal reflux disease, 10% to 15% of patients may have unsuccessful results as a result of abnormal restoration of the esophagogastric junction. The purpose of this study was to evaluate the postoperative endoscopic and radiologic characteristics of the antireflux barrier and their correlation with the postoperative results. After surgery, endoscopic and radiologic features of the antireflux wrap were evaluated in 120 consecutive patients. Jobe's classification of the postoperative valve was used for the definition of a "normal" or "defective" wrap. Patients were evaluated 3 to 5 years later in order to determine the clinical and objective failed fundoplication. A "normal" antireflux wrap was associated with successful results in 81.7% of the patients. On the contrary, defective radiologic or endoscopic antireflux wrap was observed in 19% of cases. Among these patients, hypotensive lower esophageal sphincter was observed in 50% to 65% of patients, abnormal 24-hour pH monitoring in 91%, and recurrent postoperative erosive esophagitis in 50% of patients, respectively (P < 0.001). "Defective" antireflux fundoplication is associated with recurrent reflux symptoms, presence of endoscopic esophagitis, hypotensive lower esophageal sphincter, and abnormal acid reflux.

Outcomes of esophageal surgery, especially of the lower esophageal sphincter

This paper includes commentaries on outcomes of esophageal surgery, including the mechanisms by which fundoduplication improves lower esophageal sphincter (LES) pressure; the efficacy of the Linx™ management system in improving LES function; the utility of radiologic characterization of antireflux valves following surgery; the correlation between endoscopic findings and reported symptoms following antireflux surgery; the links between laparoscopic sleeve gastrectomy and decreased LES pressure, endoscopic esophagitis, and gastroesophageal reflux disease (GERD); the less favorable outcomes following fundoduplication among obese patients; the application of bioprosthetic meshes to reinforce hiatal repair and decrease the incidence of paraesophageal hernia; the efficacy of endoluminal antireflux procedures, and the limited efficacy of revisional antireflux operations, underscoring the importance of good primary surgery and diligent work-up to prevent the necessity of revisional procedures.

Clinical significance of hiatal hernia

The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted "two-sphincter hypothesis." The gastroesophageal junction is an anatomically complex area with an inherent antireflux barrier function. However, the gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD. Because GERD may lead to reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma, a better understanding of this association is warranted. Hiatal hernias can be diagnosed radiographically, endoscopically or manometrically, with each modality having its own limitations, especially in the diagnosis of hiatal hernias less than 2 cm in length. In the future, high resolution manometry should be a promising method for accurately assessing the association between hiatal hernias and GERD. The treatment of a hiatal hernia is similar to the management of GERD and should be reserved for those with symptoms attributable to this condition. Surgery should be considered for those patients with refractory symptoms and for those who develop complications, such as recurrent bleeding, ulcerations or strictures.

Clinical significance of hiatal hernia

The relationship between hiatal hernias and gastroesophageal reflux disease (GERD) has been greatly debated over the past decades, with the importance of hiatal hernias first being overemphasized and then later being nearly neglected. It is now understood that both the anatomical (hiatal hernia) and the physiological (lower esophageal sphincter) features of the gastroesophageal junction play important, but independent, roles in the pathogenesis of GERD, constituting the widely accepted "two-sphincter hypothesis." The gastroesophageal junction is an anatomically complex area with an inherent antireflux barrier function. However, the gastroesophageal junction becomes incompetent and esophageal acid clearance is compromised in patients with hiatal hernia, which facilitates the development of GERD. Of the different types of hiatal hernias (types I, II, III, and IV), type I (sliding) hiatal hernias are closely associated with GERD. Because GERD may lead to reflux esophagitis, Barrett's esophagus and esophageal adenocarcinoma, a better understanding of this association is warranted. Hiatal hernias can be diagnosed radiographically, endoscopically or manometrically, with each modality having its own limitations, especially in the diagnosis of hiatal hernias less than 2 cm in length. In the future, high resolution manometry should be a promising method for accurately assessing the association between hiatal hernias and GERD. The treatment of a hiatal hernia is similar to the management of GERD and should be reserved for those with symptoms attributable to this condition. Surgery should be considered for those patients with refractory symptoms and for those who develop complications, such as recurrent bleeding, ulcerations or strictures.

Functional lumen imaging probe to assess geometric changes in the esophagogastric junction following endolumenal fundoplication

BACKGROUND

The functional lumen imaging probe (FLIP) uses impedance planimetry to measure the geometry of a distensible organ. The purpose of this study was to evaluate FLIP as a method to determine structural changes at the gastroesophageal junction (GEJ) following transoral incisionless fundoplication (TIF) and compare these findings with the accepted methods of esophageal testing.

METHODS

Two different approaches (TIF1.0 and 2.0) using the EsophyX™ device were performed in six and five animals, respectively. Three dogs underwent a sham procedure. FLIP measurements were performed pre- and post-procedure and at 2-week follow-up. Upper endoscopy, manometry, and 48-h pH testing were also performed at each time point. FLIP was performed in ten patients before and 3 months after TIF.

RESULTS

Following TIF procedures, there was a significant decrease in cross-sectional area (CSA) of GEJ compared to baseline; however, the CSA of both groups returned to baseline at 2-week follow-up. The FLIP results were supported with pH testing and correlated highly with both measures of GEJ structural integrity (LES and cardia circumference). Following TIF in humans, there was a decrease in GEJ distensibility compared to baseline that persisted to the 3-month evaluation.

CONCLUSION

FLIP is able to measure and display changes in tissue distensibility at the GEJ, and results correlate with established methods of testing. FLIP may represent a single testing modality by which to diagnose GERD and evaluate the outcome after antireflux surgery.

Clinical and pH-metric outcomes of transoral esophagogastric fundoplication for the treatment of gastroesophageal reflux disease

BACKGROUND

Transoral treatment of gastroesophageal reflux disease (GERD) using the EsophyX device enables creation of an esophagogastric fundoplication with potential for better control of reflux than gastrogastric techniques. Efficacy and safety of a rotational/longitudinal esophagogastric transoral incisionless fundoplication (TIF) was evaluated retrospectively using subjective and objective outcomes.

METHODS

Thirty-seven consecutive patients on antisecretory medication and with proven gastroesophageal reflux and limited hiatal hernia underwent TIF for persistent GERD symptoms. Five patients were reoperations for failed laparoscopic fundoplication.

RESULTS

Of the 37 treated patients, 57% were female. The median age was 58 (range=20-81) years and BMI was 25.5 (range=15.9-36.1) kg/m2. Sixty-eight percent indicated GERD-associated cough, asthma, or aspiration as a primary complaint and 32% complained of heartburn or regurgitation. The TIF procedures created tight wraps of 230°-330° extending 3-4 cm above the Z-line. Two complications occurred: one mediastinal abscess treated laparoscopically and one postoperative bleeding requiring transfusion. At 6 (range=3-14) months median follow-up TIF resulted in a significant improvement of both atypical and typical symptoms in 64% and 70-80% of patients, respectively, as indicated by the corresponding GERD health-related quality of life (HRQL) and reflux symptom index (RSI) score reduction by 50% or more compared to baseline on proton pump inhibitors (PPIs). No patient reported problems with dysphagia, bloating, or excess flatulence, and 82% were not taking any PPIs. Reflux characteristics were significantly improved and normalized in 61, 89, and 56% of patients in terms of acid exposure, number of refluxates, and DeMeester scores, respectively. TIF was effective in treating GERD in 75% of patients among whom 54% were in a complete "remission" and 21% were "improved." The remaining 25% were considered failures, and five (13.5%) patients underwent revision.

CONCLUSION

Rotational/longitudinal esophagogastric fundoplication using the EsophyX device significantly improved symptomatic and objective outcomes in over 70% of patients at median 6-month follow-up. Post-fundoplication side effects were not reported after TIF.

The size of the esophageal hiatus in gastroesophageal reflux pathophysiology: outcome of intraoperative measurements

OBJECTIVE

The aim of the study was to investigate the impact of the size of the esophageal hiatus on lower esophageal sphincter pressure (LESP) and acid reflux.

METHODS

Patients with gastroesophageal reflux disease who underwent Nissen fundoplication in 2006-2008 were included. All underwent esophageal manometry and 22 had 24-h pH monitoring. The area of the esophageal hiatus was calculated from a photograph shot during surgery. A hiatal index was calculated via division of hiatal area with body mass index (BMI). Correlation and logistic regression analysis were performed.

RESULTS

Twenty-eight patients (average age 44, 14 males) were enrolled. The mean BMI, LESP, DeMeester score, hiatal area, and hiatal index were 27 +/- 3.9 kg/m(2), 11.7 +/- 6.6 mmHg, 43 +/- 34, 3.83 +/- 1.24 cm(2), and 0.143 +/- 0.048, respectively. There was a significant negative correlation between hiatal area, hiatal index and LESP (-0.513, p = 0.005, r = -0.439, p = 0.019 respectively). Additionally there was a negative correlation between hiatal area and total LES length (r = -0.508, p = 0.013) and a significant positive correlation between hiatal area, hiatal index, and DeMeester scores (0.452, p = 0.035, 0.537, p = 0.01, respectively). Height and hiatal area were significant factors in multiple linear regression.

CONCLUSIONS

The size of the esophageal hiatus significantly affects LESP and acid reflux, and hiatal index is a new value, which appears to reflect the amount of acid reflux. Total LES length is also shortened in patients with a large hiatus.

Antireflux transoral incisionless fundoplication using EsophyX: 12-month results of a prospective multicenter study

Background

A novel transoral incisionless fundoplication (TIF) procedure using the EsophyX system with SerosaFuse fasteners was designed to reconstruct a full-thickness valve at the gastroesophageal junction through tailored delivery of multiple fasteners during a single-device insertion. The safety and efficacy of TIF for treating gastroesophageal reflux disease (GERD) were evaluated in a prospective multicenter trial.

Methods

Patients (n = 86) with chronic GERD treated with proton pump inhibitors (PPIs) were enrolled. Exclusion criteria included an irreducible hiatal hernia > 2 cm.

Results

The TIF procedure (n = 84) reduced all hiatal hernias (n = 49) and constructed valves measuring 4 cm (2–6 cm) and 230° (160°–300°). Serious adverse events consisted of two esophageal perforations upon device insertion and one case of postoperative intraluminal bleeding. Other adverse events were mild and transient. At 12 months, aggregate (n = 79) and stratified Hill grade I tight (n = 21) results showed 73% and 86% of patients with ≥50% improvement in GERD health-related quality of life (HRQL) scores, 85% discontinuation of daily PPI use, and 81% complete cessation of PPIs; 37% and 48% normalization of esophageal acid exposure; 60% and 89% hiatal hernia reduction; and 62% and 80% esophagitis reduction, respectively. More than 50% of patients with Hill grade I tight valves had a normalized cardia circumference. Resting pressure of the lower esophageal sphincter (LES) was improved significantly (p < 0.001), by 53%. EsophyX-TIF cured GERD in 56% of patients based on their symptom reduction and PPI discontinuation.

Conclusion

The 12-month results showed that EsophyX-TIF was safe and effective in improving quality of life and for reducing symptoms, PPI use, hiatal hernia, and esophagitis, as well as increasing the LES resting pressure and normalizing esophageal pH and cardia circumference in chronic GERD patients.

The integrity of esophagogastric junction anatomy in patients with isolated laryngopharyngeal reflux symptoms

BACKGROUND

Distortion of esophagogastric junction anatomy in patients with gastroesophageal reflux disease produces permanent dilation of the gastric cardia proportional to disease severity, but it remains unclear whether this mechanism underlies reflux in patients with isolated laryngopharyngeal reflux symptoms.

METHOD

In a prospective study, 113 patients were stratified into three populations based on symptom complex: laryngopharyngeal reflux symptoms, typical reflux symptoms, and both laryngopharyngeal and typical symptoms. Subjects underwent small-caliber upper endoscopy in the upright position. Outcome measures included gastric cardia circumference, presence and size of hiatal hernia, and prevalence of esophagitis and Barrett's esophagus within each group.

RESULTS

There were no differences in gastric cardia circumference between patient groups. The prevalence of Barrett's esophagus was 20.4% overall and 15.6% in pure laryngopharyngeal reflux patients. Barrett's esophagus patients had a greater cardia circumference compared to those without it. In the upright position, patients with isolated laryngopharyngeal reflux display the same degree of esophagogastric junction distortion as those with typical reflux symptoms, suggesting a similar pathophysiology.

CONCLUSION

This indicates that, although these patients may sense reflux differently, they have similar risks as patients with typical symptoms. Further, the identification of Barrett's esophagus in the absence of typical reflux symptoms suggests the potential for occult disease progression and late discovery of cancer.

Transoral endoscopic fundoplication in the treatment of gastroesophageal reflux disease: the anatomic and physiologic basis for reconstruction of the esophagogastric junction using a novel device

OBJECTIVE

To determine the safety, mechanism of action, immediate postprocedural anatomic impact on the esophagogastric junction, and short-term efficacy of the first entirely endolumenal antireflux procedure.

BACKGROUND

A safe and effective endoscopic antireflux procedure remains elusive. Transoral endolumenal surgery has enormous potential for the treatment of gastroesophageal reflux disease (GERD) and other esophagogastric diseases. A canine model was used to study a novel endoscopic device, which allows for creation of an endoluminal fundoplication.

METHODS

The transoral incisionless fundoplication (TIF) was performed in 21 canines in a phase I feasibility and safety study, and in 21 canines in a phase II study that included a detailed objective assessment of the effects of 2 variants of the TIF procedure (TIF 1.0 and TIF 2.0) versus sham on esophageal physiology and esophagogastric junction (EGJ) anatomy.

RESULTS

In phase I, TIF provided a safe and feasible endolumenal therapy for GERD, with histologic data that demonstrated serosal fusion of approximated full-thickness tissue plications and durability of the fundoplication. TIF procedures effectively reduced cardia circumference and improved Hill classification grade. In phase II, the TIF 2.0 procedure achieved normalization of distal esophageal acid exposure and increased lower esophageal sphincter (LES) pressure and length based on objective testing over a 2-week period. TIF 2.0 demonstrated superior results to TIF 1.0, and valve appearance and location exhibited similarity to the Nissen fundoplication by vector volume analysis.

CONCLUSIONS

The TIF procedure is safe and results in a durable and functional fundoplication as well as a platform for further development and modification of the procedure, which can be use to impact outcome. This work provides the foundation for human translation and assessment of long-term outcomes.

Pathogenesis of gastro-oesophageal reflux disease and novel options for its therapy

Better understanding of the mechanisms that lead to reflux disease is an important area for future research, given the very high prevalence of this problem. During the lifetime of this journal, much has been learnt about the pathophysiology of reflux disease. Abnormally, frequent acid reflux plays a key role in pathogenesis: this reflux occurs predominantly during transient lower oesophageal sphincter relaxations. Analysis of the literature suggests that the importance of transient relaxations as the major permissive event for occurrence of acid reflux is currently substantially underestimated. 'Transient relaxation' is an inexact descriptor, as this motor programme includes inhibition of the diaphragmatic hiatus and distal oesophageal body circular muscle and contraction of the oesophageal longitudinal muscle. Laxity of the diaphragmatic hiatus and hiatus hernia are probably important factors that increase the probability for acid reflux to occur during transient relaxations and in allowing strain-induced reflux episodes. The importance of straining and low basal tone of the lower oesophageal sphincter in causing abnormal reflux has probably been overestimated, but these need more investigation. High resolution manometry is the key method for acquisition of important new insights into the normal and disordered mechanics of the antireflux function of the gastro-oesophageal junction, but as yet, the potential of this technique has been tapped relatively little. In the future, improved understanding of the mechanics of the gastro-oesophageal junction should lead to improved physical antireflux procedures. Much progress has been made in defining the control of transient relaxations and this has been translated into several promising options for a new class of drug that treats reflux disease by inhibition of transient relaxations. Clinical trials on these agents appear imminent.

Approaches to the diagnosis and grading of hiatal hernia

Hiatus hernia refers to conditions in which elements of the abdominal cavity, most commonly the stomach, herniate through the oesophageal hiatus into the mediastinum. With the most common type (type I or sliding hiatus hernia) this is associated with laxity of the phrenooesophageal membrane and the gastric cardia herniates. Sliding hiatus hernia is readily diagnosed by barium swallow radiography, endoscopy, or manometry when greater than 2 cm in axial span. However, the mobility of the oesophagogastric junction precludes the reliable detection of more subtle disruption by endoscopy or radiography. Detecting lesser degrees of axial separation between the lower oesophageal sphincter and crural diaphragm can only be reliably accomplished with high-resolution manometry, a technique that permits real time localization of these oesophagogastric junction components without swallow or distention related artefact.