Hiatal hernia (HH) is a common condition. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of HH.

Systematic reviews were conducted for four key questions regarding the treatment of HH in adults: surgical treatment of asymptomatic HH versus surveillance; use of mesh versus no mesh; performing a fundoplication versus no fundoplication; and Roux-en-Y gastric bypass (RYGB) versus redo fundoplication for recurrent HH. Evidence-based recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations methodology by subject experts. When the evidence was insufficient to base recommendations on, expert opinion was utilized instead. Recommendations for future research were also proposed.

The panel provided one conditional recommendation and two expert opinions for adults with HH. The panel suggested routinely performing a fundoplication in the repair of HH, though this was based on low certainty evidence. There was insufficient evidence to make evidence-based recommendations regarding surgical repair of asymptomatic HH or conversion to RYGB in recurrent HH, and therefore, only expert opinions were offered. The panel suggested that select asymptomatic patients may be offered surgical repair, with criteria outlined. Similarly, it suggested that conversion to RYGB for management of recurrent HH may be appropriate in certain patients and again described criteria. The evidence for the routine use of mesh in HH repair was equivocal and the panel deferred making a recommendation.

These recommendations should provide guidance regarding surgical decision-making in the treatment of HH and highlight the importance of shared decision-making and consideration of patient values to optimize outcomes. Pursuing the identified research needs will improve the evidence base and may allow for stronger recommendations in future evidence-based guidelines for the treatment of HH.

Introduction In obese patients, hiatal hernia (HH) can be asymptomatic or may present with one or few symptoms, such as heartburn, nausea, or vomiting. Routine upper gastrointestinal (GI) endoscopy is the most frequent method used to determine the presence of any abnormalities, including HH. This study aimed to assess the prevalence of asymptomatic HH in obese patients during routine upper GI endoscopy assessments and to examine the correlation with body mass index (BMI). Materials and methods This was an observational, retrospective cohort study conducted at King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia. The data were extracted from the medical records and electronic charts of all obese patients who underwent preoperative upper GI endoscopy assessment between January 2017 and December 2019. Data were tabulated in Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) Version 21 (IBM Corp., Armonk, NY, USA). Results Among the 690 obese patients, HH was found in 103 (14.9%) patients. The chi-square test revealed that abdominal pain (X2=3.885; p=0.049), shortness of breath (X2=8.057; p=0.005), vomiting (X2=4.302; p=0.038), nausea (X2=4.090; p=0.043), and other HH symptoms (X2=3.897, p=0.048) were the most frequently reported HH related symptoms, but BMI was not (X2=2.126; p=0.345). In the multivariate regression model, the use of PPI (proton-pump inhibitor) medication (adjusted OR [AOR]=0.237; 95% CI=0.074-0.760; p=0.023) was found to be higher in those with HH. Vomiting (AOR=1.722; 95% CI=1.025-2.890; p=0.040) and nausea (AOR=1.698; 95% CI=1.012-2.849; p=0.045) were the most frequently reported symptoms related to HH. Conclusion Asymptomatic HH among obese patients is not widely prevalent in our region. The use of PPI medications was found to decrease the symptoms associated with HH, such as vomiting and nausea. However, there was no evidence linking BMI to the development of HH.

The confluence between the increased prevalence of gastro-esophageal reflux disease (GERD) and of obesity has generated great interest in the association between these two conditions. Several studies have addressed the potential relationship between GERD and obesity, but the exact mechanism by which obesity causes reflux disease still remains to be clearly defined. A commonly suggested pathogenetic pathway is the increased abdominal pressure which relaxes the lower esophageal sphincter, thus exposing the esophageal mucosal to gastric content. Apart from the mechanical pressure, visceral fat is metabolically active and it has been strongly associated with serum levels of adipo-cytokines including interleukin-6 and tumor necrosis factor α, which may play a role in GERD or consequent carcinogenesis. This summary is aimed to explore the potential mechanisms responsible for the association between GERD and obesity, and to better understand the possible role of weight loss as a therapeutic approach for GERD.

This study estimated the prevalence and clinical spectrum of gastroesophageal reflux disease (GERD) in Asan-si, Korea, as the prevalence is believed to be lower than in Western countries.

A cross-sectional survey, using a reliable and valid questionnaire, was performed on randomly selected 2,240 Asan-si residents aged between 18 and 69 yr. All respondents were interviewed at their homes or offices by a team of interviewers.

Of the 1,902 eligible subjects, 1,417 (78.4%: male 762; female 655) were surveyed. The prevalence of heartburn occurring at least once a month, at least once a week, and at least twice a week was 4.71% (95% confidence interval (CI), 3.6-5.8), 2.0% (95% CI, 1.2-2.7), and 1.3% (95% CI, 0.7-1.9), respectively. The corresponding figures for acid regurgitation were 4.4% (95% CI, 3.3-5.5) and 2.0% (95% CI, 1.3-2.8), respectively. The prevalence of GERD, defined as heartburn and/or acid regurgitation experienced at least weekly, was 3.5% (95% CI, 2.6-4.5). No significant difference was detected between sexes. The prevalence of heartburn was associated with increasing age (p < 0.001). Nineteen percent of our population reported at least one of the atypical symptoms, for instance, chest pain, dysphagia, globus sensation, asthma, bronchitis, pneumonia, or hoarseness. The frequency of frequent GERD among subjects reporting any of the atypical symptoms was 12.6%, which was higher than that of the subjects without atypical symptoms. Patients with typical reflux symptoms were more common among those with atypical symptoms, compared to those without such symptoms (p < 0.001). Using a logistic regression model after adjusting for age and sex, typical reflux symptoms were associated with chest pain (odds ratio (OR), 9.3; 95% CI, 5.9-14.7), dysphagia (OR, 6.4; 95% CI, 2.8-14.7), globus sensation (OR, 3.9; 95% CI, 1.5-9.7), hoarseness (OR, 4.3; 95% CI, 1.4-13.1), asthma (OR, 2.6; 95% CI, 1.4-4.8), and bronchitis (OR, 1.2; 95% CI, 0.6-2.3).

The prevalence of GERD was 3.5% in this Korean population. Heartburn and acid regurgitation were significantly associated with chest pain, dysphagia, globus sensation, hoarseness, and asthma.

Helicobacter pylori infection and atrophic gastritis are inversely related to erosive esophagitis. Whether these factors affect the pathogenesis of endoscopy-negative reflux disease is not clear. We aimed to elucidate the differences in clinical characteristics between endoscopy-negative erosive disease and erosive esophagitis.

253 subjects (89 with endoscopy-negative reflux disease and 164 with erosive esophagitis) were studied. Gastric atrophy was assessed by measurement of serum pepsinogen. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence intervals (CI) of endoscopy-negative reflux disease compared with erosive esophagitis.

Among GERD patients, female gender (OR = 2.27, 95% CI, 1.25-4.10), smoking (OR = 0.45, 95% CI, 0.22-0.91), and the presence of hiatal hernia (OR = 0.30, 95% CI, 0.17-0.56) were significantly associated with endoscopy-negative reflux disease compared with male gender, not smoking, and absence of hiatal hernia, respectively. Body mass index (BMI) was also significantly associated with a decreased OR for endoscopy-negative reflux disease. Although H. pylori infection and gastric atrophy were significantly more common in patients with endoscopy-negative reflux disease, these associations did not persist in a multiple-adjustment model. After adjustment for gender, BMI, smoking, and hiatal hernia, a decrease in serum pepsinogen I/II ratio was significantly associated with an increased OR for endoscopy-negative reflux disease (p for trend = 0.018).

Female gender, low BMI, not smoking, absence of hiatal hernia, and severity of gastric atrophy were positively associated with endoscopy-negative reflux disease compared with erosive esophagitis among Japanese patients.

The major oesophageal complications associated with persistent gastro-oesophageal reflux disease (GERD) include erosive oesophagitis, ulceration, strictures and gastrointestinal (GI) bleeding. Although the causes of these complications are uncertain, studies indicate that erosive oesophagitis may progress to the development of ulcers, strictures and GI bleeding. Pharmacological treatment with proton pump inhibitors is favoured over that with H(2)-receptor antagonists for the treatment of strictures. The treatment of strictures is accomplished with dilation and many favour the concomitant use of proton pump inhibitors. Most gastroenterologists are seeing far fewer oesophageal strictures these days since the introduction of proton pump inhibitors. In addition, research has shown that oesophageal complications have a greater impact on patients suffering from night-time GERD than on those suffering from daytime GERD. Barrett's oesophagus is a significant complication associated with persistent GERD and those at risk generally experience a longer duration of symptoms, especially those with a high degree of severity. In addition, there is a strong relationship between Barrett's oesophagus and oesophageal adenocarcinoma. This is in part due to the association of obesity and the development of hiatal hernias. Furthermore, endoscopic screening is being used to detect Barrett's oesophagus and oesophageal adenocarcinoma in persons suffering from chronic GERD, even though screening may not have an impact on outcomes (Sharma P, McQuaid K, Dent J, et al. A critical review of the diagnosis and management of Barrett's esophagus: The AGA Chicago Workshop. Gastroenterology 2004; 127: 310-30.).

The prevalence of gastro-oesophageal reflux disease (GERD) in Asian populations is reported to be lower than that in Western populations. However, recent epidemiological studies suggest that the incidence of the disease is increasing, especially in Japan. Endoscopic studies show that the overall prevalence of reflux oesophagitis among the adult population in Japan is in the region of 14-16%. This is similar to the figure reported in Western countries. The increasing prevalence in Japan may be due to a number of factors including increasing awareness of the condition and improved diagnostic techniques. The majority of the diagnosed cases in Japan are mild and these account for the increase in prevalence of the condition. In contrast to the West, where the condition is more prevalent in male members of the population, there is a high incidence of GERD in elderly females in Japan. The increased incidence of kyphosis and osteoporosis in this population may lead to the development of hiatus hernia, a condition known to exacerbate the development of reflux disease. Furthermore, Japanese patients with endoscopically diagnosed GERD appear to be less likely to complain of typical reflux symptoms, such as heartburn and acid reflux than their Western counterparts. In view of the known relationship between asymptomatic GERD and the development of oesophageal cancers there is a strong case for increased vigilance in the detection of GERD in the Japanese population.

This article reviews the epidemiology of cancers arising in the distal oesophagus and proximal stomach, sometimes collectively termed oesophago-gastric junctional adenocarcinomas. The several complexities involved in defining this group of cancers are considered and the reported increasing trends in incidence are reviewed, together with the descriptive epidemiology. The rates of these cancers are increasing, but not as dramatically as sometimes reported. They are also more common in white males than in other ethnic groups or in females. Although several aetiological risk factors have been reported, the two most consistent are an elevated body mass index (obesity) and a history of gastro-oesophageal reflux disease. Reflux is also associated with Barrett's oesophagus, an important and increasingly diagnosed premalignant lesion. The rate of progression from Barrett's oesophagus to cancer is controversial, as is the cost-benefit balance of routine endoscopic surveillance of such patients. The development of molecular biomarkers to identify Barrett's oesophagus patients with high rates of malignant transformation would represent a significant advance.

Gastroesophageal reflux disease can be divided into three categories: nonerosive GERD (NERD), erosive GERD (ERD), and Barrett's esophagus. A shift among these categories rarely occurs. The aim of the present study was to elucidate potential patient-associated risk factors associated with ERD.

A total of 6,215 patients with troublesome heartburn were recruited to a large, prospective, multicenter open cohort study comprising an initial treatment phase and a 5-yr follow-up phase. Each center planned to recruit an equal number of patients with NERD and ERD. All patients underwent an interview based on standardized questionnaires, a physical examination, and endoscopy with biopsies. Data were analyzed by multiple logistic regression analysis.

Risk factor analysis was performed on 5,289 patients (NERD: n = 2,834; ERD: n = 2,455), which was the intent-to-treat population excluding patients with suspected/proven complicated reflux disease. Stepwise regression analysis identified the following independent predictors of ERD: male gender, overweight, regular use of alcohol, a history of GERD >1 yr, and smoker or ex-smoker. A higher level of education and a positive Helicobacter pylori (H. pylori) status were associated with a lower risk of ERD.

Some patient-associated factors increase the risk of erosive esophagitis as opposed to nonerosive reflux disease. However, no single factor or combination of factors is capable of predicting mucosal damage with clinically sufficient certainty. Thus, endoscopy is still required in all GERD patients if valid information on the state of the esophageal mucosa is needed.

This report summarizes the conclusions and recommendations of a panel of gastroenterologists practising in the Asia-Pacific region. The group recognized that although gastroesophageal reflux disease (GERD) is less common and milder in endoscopic severity in Asia than in the West, there is nevertheless data to suggest an increasing frequency of the disease. During a 2-day workshop, the evidence for key issues in the diagnosis and clinical strategies for the management of the disease was evaluated, following which the recommendations were made and debated. The consensus report was presented at the Asia-Pacific Digestive Week 2003 in Singapore for ratification. Upper gastrointestinal (GI) endoscopy is the gold standard for the diagnosis of erosive GERD. There is no gold standard for the diagnosis of non-erosive GERD (NERD). Diagnosis therefore relies on symptoms, a positive 24-h pH study or a response to a course of proton pump inhibitor (PPI) treatment. The goals of treatment for GERD are to heal esophagitis, relieve symptoms, maintain the patient free of symptoms, improve quality of life and prevent complications. The PPI are the most effective medical treatment. Following initial treatment, on-demand therapy may be effective in some patients with NERD or mild (GI) erosive esophagitis. Anti-reflux surgery by a competent surgeon could achieve a similar outcome, although there is an operative mortality of 0.1-0.8%. The decision is dependent on the patient's preference and the availability of surgical expertise. Currently, endoscopic treatment should be performed only in the context of a clinical trial. Treatment of patients with typical GERD symptoms without alarm features in primary care could begin with PPI for 2 weeks followed by a further 4 weeks before going to on-demand therapy.

Data on the incidence of hiatus hernia are lacking. A cross-sectional study was performed in a large population of consecutive patients undergoing endoscopy in order to assess the yearly incidence of hiatus hernia in this population.

Consecutive patients undergoing upper gastrointestinal endoscopy in whom no macroscopic abnormalities were seen and who, in addition, underwent a second endoscopy were included in the study. The presence of newly developed hiatus hernia was noted, as well as the time elapsed between both endoscopies.

Over a period of 8 years, 12 122 endoscopies were performed in 9580 patients. Ninety patients developed a hiatus hernia; this was not the case in a control group of 353 patients. Patients who developed a hiatus hernia were significantly older than those who did not (P < 0.001). The number of women who developed hiatus hernia was higher than the number of men who developed hiatus hernia (P < 0.0001). The total time between both endoscopies in 443 patients was 897 patient years. Ninety patients (20.3%) developed a hiatus hernia. If these data are extrapolated to a yearly occurrence, then 35 of 176 patients will develop a hiatus hernia. It takes an average of 1.9 years for a hiatus hernia to develop.

In the present study, it was calculated that 19.9% of the studied population would develop a hiatus hernia per year. Patients who developed a hiatus hernia were significantly older than patients who did not. The present study also shows that a hiatus hernia actually develops later in life.

Organic and inorganic constituents of saliva have been implicated as protective components in the esophagus, and deficiencies in one or more of these factors in different races may be an important element in the prevalence of gastroesophageal reflux disease (GERD). To determine whether there are differences in the concentration of salivary mucins between different racial groups, we measured the concentration of mucous glycoprotein MG1 and mucous glycoprotein MG2 in whole saliva of African-Americans and Caucasians.

Whole saliva was collected from 19 African-American (four male, 15 female; mean age 34 yr, range 19-53 yr) and 25 Caucasian (11 male, 14 female; mean age 31 yr, range 20-51 yr) volunteers under masticatory stimulation (1 g Parafilm, 60 strokes/min) between 11:00 AM and 12:00 noon. Total salivary carbohydrate was measured with a periodic acid-Schiff assay and total protein by absorbance at 215 nm. Immunological reagents were employed to quantify MG2 in a combined enzyme-linked immunosorbent assay/enzyme linked lectin assay (ELISA/ELLA) and to quantify MG1 in a capture ELISA.

The total carbohydrate, protein, MG1 and MG2 values were 24.4 +/- 11.9, 243.5 +/- 62.7, 21.8 +/- 13.4, and 11.6 +/- 9.5 mg% for African-Americans, and the corresponding values were 23.3 +/- 9.3, 221.7 +/- 39.7, 25.7 +/- 16.2, and 10.9 +/- 8.7 mg% for Caucasians. There was no statistical difference for any of the parameters measured between the two groups. Furthermore, it was shown that no correlation existed between salivary flow rate and the concentration of carbohydrate, protein, or salivary mucins in African-Americans and in Caucasians. These results show that flow rate did not influence the measured values for salivary parameters in the two groups.

No differences were found in the concentration of salivary mucins MG1 and MG2 in whole saliva of African-Americans and Caucasians, and it seems unlikely that variations in mucin levels influence the prevalence of GERD in these groups.