
==== Front
Gastroenterol Rep (Oxf)
Gastroenterol Rep (Oxf)
gastro
Gastroenterology Report
2052-0034
Oxford University Press

10.1093/gastro/goae086
goae086
Original Article
AcademicSubjects/MED00260
Hiatal hernia: risk factors, and clinical and endoscopic aspects in gastroscopy
Abu-Freha Naim Assuta Medical Center, Gastroenterology Institute, Beer-Sheva, Israel
Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel

Guterman Revital Assuta Medical Center, Gastroenterology Institute, Beer-Sheva, Israel

Elhayany Ruhama Hospital Administration, Assuta Medical Center, Beer Sheva, Israel

Yitzhak Avraham Hospital Administration, Assuta Medical Center, Beer Sheva, Israel

Hudes Shira Sophie Medical School for International Health, Ben Gurion University of the Negev, Beer-Sheva, Israel

Fich Alexander Assuta Medical Center, Gastroenterology Institute, Beer-Sheva, Israel
Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel

Corresponding author. Institute of Gastroenterology, Assuta Hospital, Beer-Sheva, Yitzhack Rager Blvd 11, Tower 7, Beer-Sheva 8489507, Israel. Tel: +972-8-6402251; Fax: +972-8-6233083; Email: naima@assuta.co.il; abufreha@yahoo.de
2024
12 9 2024
12 9 2024
12 goae08627 1 2024
14 3 2024
28 5 2024
© The Author(s) 2024. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-sen University
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

Abstract

Background

Hiatal hernia (HH) is a common finding in gastroscopy. The aim of the present study was to investigate the frequency rate of HH among patients who underwent esophagogastroduodenoscopy (EGD) according to their age, gender, and procedural indication.

Methods

A multicenter, retrospective study including all EGDs was conducted across seven endoscopy departments between 2016 and 2021. Demographic information, procedural indications, and findings from the initial EGD were collected.

Results

Of the 162,608 EGDs examined, 96,369 (59.3%) involved female patients. HH was identified in 39,619 (24.4%) of all EGDs performed, comprising small HH in 31,562 (79.6%) and large HH in 3,547 (9.0%). The frequency of HH was 16.5% in the age group of ≤50 years and 37.3% in those aged ≥81 years. HH was diagnosed in 38.7% (11,370) of patients with heartburn/reflux symptoms, 31.5% of those with dysphagia, 28.5% of those with positive fecal occult blood tests, and 24.3% of those who would undergo bariatric surgery. Age (odds ratio 1.030), female gender (odds ratio 1.309), reflux symptoms (odds ratio 2.314), and dysphagia (odds ratio 1.470) were identified as predictors for HH.

Conclusions

Risk factors for HH diagnosed by EGD in symptomatic patients were shown to be advanced age, female gender, and the presence of heartburn or dysphagia.

hiatal hernia
gastroscopy
risk factors
indications
==== Body
pmcIntroduction

Hiatal hernia (HH) is characterized by herniation of the stomach through the diaphragm into the mediastinum. HHs are broadly subdivided into sliding hernias (85%–95%) and paraesophageal hernias (5%–15%) [1]. Accurate data on the prevalence of HH, particularly in patients who undergo esophagogastroduodenoscopy (EGD), are not available. Determining the prevalence of HH poses challenges due to factors such as the subjectivity of the diagnostic criteria [1] and the lack of symptoms in a subset of individuals who forego any diagnostic assessment. The most common type of HH is the sliding hernia, comprising ∼85%–95% [1]. Established risk factors for HH include age and obesity [1–4], in addition to factors such as multiple pregnancies, esophageal surgery, and partial or full gastrectomy [5, 6].

While EGD is the primary diagnostic modality for most cases of HH, alternative methods, including barium swallow, computed tomography, and high-resolution manometry, may also be used [1, 7, 8]. Patients with HHs may be asymptomatic, but symptoms of reflux may be present. Additionally, complications such as Cameron lesion and iron deficiency anemia may occur, and the latter often resolves in patients with large HHs treated with surgery [9]. Medical management of symptomatic HH patients typically involves inhibition of gastric acid secretion, with surgery reserved for a select subset of individuals.

EGD is an important diagnostic and therapeutic modality in gastroenterology. Despite its pivotal role, there is a paucity of recently published literature regarding the clinical and endoscopic aspects related to HH in terms of prevalence, risk factors, and EGD findings. This study aimed to fill this gap by examining the clinical and endoscopic facets, including the frequency rate of HHs among patients undergoing EGD, stratified by age, gender, indication for the procedure, and the performing endoscopist.

Methods

Study design

Our project constituted a multicenter, large-cohort, retrospective study of EGDs performed between 2016 and 2021. Data were collected from seven Assuta endoscopy departments located in Beer-Sheva, Ashdod, Raanana, Rishon lezion, Haifa, Hashalom, and Ramat Hahayal. All EGDs performed, limited to the first procedure per patient, were included and data were retrieved from the respective endoscopy reports.

Definition of HH

A diagnosis of HH was considered when the terms “hiatal hernia” or “hiatus hernia” were explicitly mentioned in the diagnosis of the endoscopy report, or when a descriptive account of HH was documented in the EGD findings. In this study, HHs were characterized as small if they measured ≤5 cm, while large hernias were defined as cases exceeding 5 cm.

Data collection

Data were extracted from medical records and electronic charts using the MDClone platform (http://www.mdclone.com), which includes computerized patient data and data from community clinics, emergency departments, and hospitals. Data are available for each patient, including diagnoses and events such as hospitalizations, emergency department visits, surgeries, laboratory results, and medication prescriptions. Any new diagnosis, hospitalization, or medical update is recorded as a new event. The exploration of events on a linear timeline is possible due to the longitudinal data organization. Anonymous patient data can be extracted in relation to other recorded events. The MDClone platform enables a self-service big-data exploration environment. However, in our study that was performed in Assuta endoscopy departments, we had data related to endoscopy and not the entire medical file. MDClone could be used not only as a data platform, but also as a dynamic and fluid process for data exploration, analysis, and healthcare improvement.

Demographic information, indications for the procedure, and findings from the initial EGD were retrieved for each patient. Indications for the procedure included heartburn/reflux symptoms, dyspepsia/abdominal pain, celiac investigation/follow-up, positive fecal occult blood test, weight loss, family history of stomach cancer, anemia, dysphagia, nausea/vomiting, and pre-bariatric surgery evaluations. Other indications were considered uncommon, such as cough, hoarseness, bloating, follow-up of stomach polyp after bariatric surgery, esophageal varices screening, or unknown indications. EGD findings were collected based on the diagnosis and description written by the endoscopist. A Barrett’s esophagus diagnosis was considered according to the diagnosis and description of the EGD report; unfortunately, histological data were not available for the present study.

Statistical analysis

Patient characteristics were presented as mean ± standard deviation for continuous variables and as percentages for categorical variables. Categorical variables were compared using the chi-square test. Continuous variables were examined by using the Student’s t-test. Non-normally distributed continuous variables were reported as median (interquartile range) and compared using the Mann–Whitney test. Logistic regression models were used to examine the multivariate relationships between risk factors and the odds of HH. Before introducing the variables into the model, the multicollinearity of the variables was examined by using the Variance Inflation Factor statistic.

All statistical analyses were performed using IBM SPSS version 26 (Chicago, USA). P-values of <0.05 were considered statistically significant. The study protocol was approved by the Institutional Helsinki Committee of Assuta Medical Center (approval number 0075–21). Informed consent was waived due to the retrospective non-interventional study design.

Results

The data regarding patients enrolled in the study are summarized in Table 1. We included 162,608 EGDs that occurred between 10 January 2017 and 27 October 2021. The majority of the patients were female, constituting 59.3% (n = 96,369), and the mean age of the participants was 53.9 ± 15.1 years. The most common indications for EGD were abdominal pain/dyspepsia at 42.7% (n = 69,481), followed by heartburn/reflux symptoms at 18.1% (n = 29,401).

Table 1. Baseline characteristics of the study cohort

Esophagogastroduodenoscopy	n = 162,608	
Female	96,369 (59.3)	
Age, mean ± SD, years	53.9 ± 15.1	
Hiatal hernia	39,619 (24.4)	
Hernia sizea		
 Small	31,562 (79.7)	
 Large	3,547 (9.0)	
 Unknown	4,510 (11.4)	
Indications for esophagogastroduodenoscopy		
 Heartburn	29,401 (18.1)	
 Abdominal pain/dyspepsia	69,481 (42.7)	
 Celiac investigation/follow-up	1,608 (1.0)	
 Positive fecal occult blood test	1,248 (0.8)	
 Family history of gastric cancer	2,812 (1.7)	
 Weight loss	3,896 (2.4)	
 Iron deficiency anemia	15,385 (9.5)	
 Dysphagia	4,987 (3.1)	
 Nausea/vomiting	3,847 (2.4)	
 Before bariatric surgery	1,503 (0.9)	
 Other indications	31,460 (19.3)	
a A total of 39,619 hiatal hernias were diagnosed by using esophagogastroduodenoscopy.

SD = standard deviation.

HH was diagnosed in 24.4% (n = 39,619) of all EGDs conducted, with 79.6% (n = 31,562) classified as small HHs, 9% (n = 3,547) as large HHs, and 11.4% (n = 4,510) with an unknown size.

HH frequency by gender, age, indication for EGD, and endoscopist

A total of 25,165 (26.1%) females and 14,454 (21.8%) males were diagnosed with HH by using EGD (P < 0.001). Further analysis revealed an age-dependent increase in the frequency of HH for both females and males (Figure 1). The prevalence of HH by age group was 16.5% in those aged ≤50 years, 24.6% in those aged 51–60 years, 31.3% in those aged 61–70 years, 35.1% in those aged 71–80 years, and 37.3% in those aged ≥81 years. In terms of indications for the procedure, HH was prevalent in 38.7% of patients with heartburn/reflux symptoms, 31.5% of those with dysphagia, 28.5% of those with positive fecal occult stool test, 23.1% of those with nausea/vomiting, 20.8% of those with abdominal pain/dyspepsia, and 24.3% of those who would undergo bariatric surgery. Furthermore, this study also found a significant diversity in the frequency of HH diagnosis observed between different endoscopists, ranging from 6.4% to 68%.

Figure 1. Frequency rate of hiatal hernia in esophagogastroduodenoscopy among females and males.

Characteristics of patients with hiatal hernia

The characteristics of HH patients in comparison with non-HH patients are summarized in Table 2. Patients with HH were older than those without HH (58.7 ± 13.5 vs 52.4 ± 15.3 years, P < 0.001). Additionally, a higher proportion of patients with HH than patients without HH were female (63.5% vs 57.9%, P < 0.001). Abdominal pain/dyspepsia was the most common indication for EGD in both groups, with 36.7% of HH patients compared with 44.9% of non-HH patients (P < 0.001). Heartburn/reflux symptoms were the second-most common indication, with 28.7% of HH patients compared with 14.7% of non-HH patients (P < 0.001).

Table 2. Comparison of baseline characteristics and indications for esophagogastroduodenoscopy between patients with and without HH

Variable	HH group (n = 39,619)	Non-HH group (n = 122,989)	P-value	
Age, mean ± standard deviation	58.7 ± 13.5	52.4 ± 15.3	<0.001	
Female	25,165 (63.5)	71,204 (57.9)	<0.001	
Age, years			<0.001	
 <50	10,619 (26.8)	53,647 (43.6)		
 51–60	9,595 (24.2)	29,483 (24.0)		
 61–70	12,122 (30.6)	26,545 (21.6)		
 71–80	6,533 (16.5)	12,055 (9.8)		
 ≥80	750 (1.9)	1,259 (1.0)		
Indications for esophagogastroduodenoscopy	
 Heartburn/reflux symptoms	11,370 (28.7)	18,031 (14.7)	<0.001	
 Follow-up for Barrett’s esophagus	218 (0.6)	52 (0.04)	<0.001	
 Abdominal pain/dyspepsia	14,531 (36.7)	55,179 (44.9)	<0.001	
 Positive fecal occult stool test	356 (0.9)	892 (0.7)	<0.001	
 Family history of stomach cancer	550 (1.4)	2,262 (1.8)	<0.001	
 Weight loss	734 (1.9)	3,162 (2.6)	<0.001	
 Anemia	3,238 (8.2)	12,147 (9.9)	<0.001	
 Dysphagia	1,571 (4.0)	3,416 (2.8)	<0.001	
 Nausea/vomiting	888 (2.2)	2,959 (2.4)	0.061	
 Before bariatric surgery	365 (0.9)	1,138 (0.9)	0.942	
 Celiac investigation/follow-up	258 (0.7)	1,350 (1.1)	<0.001	
 Other indications	6,480 (16.4)	24,980 (20.3)	<0.001	
HH = hiatal hernia.

EGD findings in HH and non-HH groups

Esophagitis was diagnosed among 9,901 (25.0%) HH patients, which was significantly higher than the 15,049 (12.2%) among non-HH patients (P < 0.001; Table 3); the frequency rates of all severity grades of esophagitis (Los Angeles classification) were higher among the HH patients (P < 0.001). Barrett’s esophagus was diagnosed in 1,780 (4.5%) of HH patients and in 2,752 (2.2%) among non-HH patients (P < 0.001). In addition, gastritis and gastric polyps were diagnosed with a higher frequency among HH patients compared with non-HH patients (29.8% vs 24.7%, P < 0.001; 5.9% vs 4.1%, P < 0.001, respectively). Conversely, esophageal carcinoma, gastric ulcer, gastric carcinoma, and duodenal ulcer were significantly less frequent among HH patients.

Table 3. Comparison of esophagogastroduodenoscopy findings in patients with and without hiatal hernia

Variable	HH group (n = 39,619)	Non-HH group (n = 122,898)	P-value	
Esophagitis	9,901 (25.0)	15,049 (12.2)	<0.001	
 Los Angeles grade A	7,137 (18.0)	11,682 (9.5)	<0.001	
 Los Angeles grade B	2,043 (5.2)	2,603 (2.1)	<0.001	
 Los Angeles grade C	530 (1.3)	547 (0.4)	<0.001	
 Los Angeles grade D	191 (0.5)	217 (0.2)	<0.001	
Esophageal ulcer	302 (0.8)	431 (0.4)	<0.001	
Barrett’s Esophagus	1,780 (4.5)	2,752 (2.2)	<0.001	
Esophageal carcinoma	10 (0.03)	63 (0.1)	0.034	
Gastritis	11,825 (29.8)	30,322 (24.7)	<0.001	
Gastric ulcer	285 (0.7)	1,263 (1.0)	<0.001	
Gastric carcinoma	10 (0.03)	127 (0.1)	<0.001	
Duodenitis	2,115 (5.3)	6,560 (5.3)	0.972	
Duodenal ulcer	206 (0.5)	961 (0.8)	<0.001	
Gastric polyps	2,353 (5.9)	5,057 (4.1)	<0.001	

Multivariate analysis for HH diagnosis

In the multivariate model, we found significant associations between age at the time of EGD performance and odds of HH [odds ratio (OR) 1.030, P < 0.001, 95% confidence interval (CI) 1.030–1.031], as well as between female gender and odds of HH (OR 1.309, P < 0.001, 95% CI 1.287–1.341), heartburn as an indication for EGD with odds of HH (OR 2.314, P < 0.001, 95% CI 2.239–2.393), and dysphagia as an indication for EGD with odds of HH (OR 1.470, P < 0.001; 95% CI 1.377–1.568). Indications such as abdominal pain/dyspepsia, family history of stomach cancer, weight loss, or anemia were found to have a lower risk for exhibiting HH upon EGD. The results of the multivariate models are summarized in Table 4.

Table 4. Multivariate analysis for hiatal hernia diagnosis

Variable	Multivariate analysis	
Odds ratio	95% confidence interval	P-value	
Age	1.030	1.030–1.031	<0.001	
Female	1.309	1.287–1.341	<0.001	
Heartburn	2.314	2.239–2.393	<0.001	
Nausea/vomiting	1.204	1.111–1.304	<0.001	
Dysphagia	1.470	1.377–1.568	<0.001	
Obesity (before bariatric surgery)	1.571	1.390–1.775	<0.001	
Abdominal pain/dyspepsia	0.960	0.932–0.989	0.008	
Family history of stomach cancer	0.868	0.788–0.956	0.004	
Weight loss	0.748	0.687–0.814	<0.001	
Anemia	0.852	0.814–0.892	<0.001	

Discussion

The most important findings of the present study are that age, female gender, heartburn, and dysphagia are risk factors for diagnosing HH by using EGD. Our study revealed a prevalence of HHs of 24.4% among patients who underwent EGD, which is relatively close to the 20% reported in a previous prospective study of 1,224 patients [4].

A previously published meta-analysis showed an association between age of >50 years and an OR of 2.17 for HH [10]. The data from this study suggest that the HH frequency rate in those undergoing EGD increases with age, with 37,332 per 100,000 among people aged ≥80 years. The increasing frequency of HH with age could be contributed at least partly by fibromuscular degeneration as result of the aging process.

In our study, 63.5% of HH patients were female and the multivariate analysis demonstrates an OR of 1.309 for having HH in females compared with males. These findings are contrary to a previously published meta-analysis which suggested that HH was more common among men, with an OR of 1.36 [10]. On the other hand, our data noted a substantial gender-specific variation, with 26.1% of the females and 21.8% of the males diagnosed with HH, while a previous study demonstrated that 31.2% of the females who underwent EGD had HH compared with 14% of the males [11].

Overweight and obese people are at increased risk of HH because of the increase in intra-abdominal pressure that results in herniation [12]. Our study corroborated this, revealing a 24.3% HH incidence in patients who underwent EGD before bariatric surgery. A previous meta-analysis found an OR of 1.93 for HH in people with a body mass index of >25, with increasing risk according to body mass index [10]. A recently published study that included 690 obese patients who underwent EGD during preoperative bariatric surgery found that 14.9% of the patients had asymptomatic HH [13], which is lower than the rate found in our study.

In general, no symptom is specific for HH, but symptoms of gastroesophageal reflux are the most common. Our study revealed that ∼40% of patients with gastroesophageal reflux symptoms had HH in their EGD. If the abnormal findings in the EGD are focused upon, then 25% of the HH patients had esophagitis and ∼40% of the 24,950 patients who had esophagitis in the EGD were diagnosed with HH. This rate is much lower than those in previous reports that found HH in 68% of esophagitis patients [4]. Another study found that HH was significantly associated with asymptomatic erosive esophagitis, with an OR of 4.48 [14]. Moreover, a meta-analysis found an OR of 4.07 for HH as a risk factor for erosive esophagitis [15].

In summary, HH is a common finding in EGD, represented in about a quarter of patients in our study. The important risk factors found in our study were age, female gender, and heartburn or dysphagia as an indication for EGD. Over the last decade, scant data related to the clinical and endoscopic aspects of HH have been published. As such, our study provides information regarding these aspects for clinicians and patients.

The strengths of the study lie in the multicenter design and large number of procedures. However, there are several important limitations, including the retrospective design; lack of available data regarding the endoscopists’ years of experience and total number of procedures; lack of information regarding HH classification, obesity, and body mass index; and reliance solely on the EGD reports.

Conclusions

HH is prevalent among individuals who undergo gastroscopy. Age, female gender, reflux symptoms, and dysphagia were found to be significant risk factors for diagnosing a HH during EGD. These findings provide crucial information for clinicians and patients, particularly in light of the considerable indications for EGD and patients at high risk of HH.

Authors’ Contributions

N.A. was responsible for methodology and design, project management, and drafting of the manuscript. R.G. was responsible for data analysis, review of the methodology, and revision of the manuscript. R.E. was responsible for study design, data sources, review, and revision of the manuscript. A.Y. was responsible for methodology investigation, formal analysis, review, and revision of the manuscript. S.S.H. was responsible for formal analysis, analysis and interpretation of data, review, and revision of the manuscript. A.F. was responsible for methodology, investigation, and critical revision of the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.

Acknowledgements

None.

Funding

None.

Conflicts of Interest

The authors declare that there are no conflicts of interest in this study.
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