May motor disorders be responsible for hiatus hernia ?

R.E. Clouse (Washington)

This question has not been systematically studied, but some data would suggest that motor abnormalities and hiatus hernia are potentially related. The esophagus shortens in a systematic fashion with swallowing by an average of 2 cm in the human [ 1 ]. The degree of shortening in both the laboratory animal and the human is most extreme in the distal esophagus [1, 2]. It is conceivable that motility disorders of the esophagus manifested by vigorous contraction of the esophageal muscles could result in excessive shortening and unusual tension on phrenoesophageal attachments. This esophageal shortening could be a result of circular muscle contraction alone (through translational axial movement from contraction of muscle bundles with oblique orientation) or could be related to longitudinal muscle contraction [3].

We examined the prevalence of sliding hiatus hernia in patients referred for esophageal manometry who were ultimately found to have esophageal contraction abnormalities or no motor dysfunction [4]. A monotonic increase in prevalence of hiatus hernia with increasing severity of vigorous contraction wave abnormalities in the distal esophagus was found. The prevalence of hiatus hernia was only 8 p. cent in those with no manometric finding and increased to 47 p. cent in those with the most severe contraction wave abnormalities (including increased wave amplitudes, prolonged wave durations, and presence of double - - and triple - - peaked contraction waves). Prior observations also favored an association between hiatus hernia and the more severe radiographic patterns of esophageal spasm [5].

A brief report following our publication failed to support this observation, but differences in the classification of manometric pattern could largely account for the disparate findings [6]. Likewise, different standards for normal and abnormal were utilized by the different laboratories. At present, the precise relationship between these motor abnormalities and hiatus hernia remains unresolved but deserves further investigation.

References

1. Edmundowicz SA, Clouse RE (1988) Shortening of the human esophagus in response to swallows. Gastroenterology 95 : 863A.

2. Dodds WJ, Stewart ET, Hodges D, Zboralske FF (1973) Movement of the feline esophagus associated with respiration and peristalsis. J Clin Invest 52: 1-13.

3. Christensen J (1983) The esophagus. In : Christensen J, Wingate DL, eds. A guide to gastrointestinal motility. London, Wright, 75-100.

4. Clouse RE, Eckert TC, Staiano A (1986) Hiatus hernia and esophageal contraction abnormalities. Am J Med 81 : 447-450.

5. Texter EC Jr, Lazar HP, Puletti EJ, Van Derstappen G, Danovitch SH, Douglas WW (1967) Hiatal

Hernia. In: The stomach including related areas in the esophagus and duodenum. Thompson CM, Berkowitz D, Polishell E, Moyer JY, eds. New York, Grune and Stratton 54-71. 6. Ott DJ, Chen YM, Richter JE, Wu WC (1987) Hiatus hernia and esophageal contraction abnormalities. Am J Med 82 : 859.