Comparative assessment of clinical and endoscopic semiotics of hiatal hernias
Authors: Tarasov T. A. , Markulan L. Y. 
Published: November 2023

A hiatal hernia (HH) of type III combines the anatomical characteristics of HH types I and II. The manifestations of type III HHs are diverse, and they can originate from either type I or type II, but so far, there is no certainty regarding the correlation between the clinical and endoscopic manifestations of HH type III and its origin.

Objective —  Based on the analysis of clinical and endoscopic manifestations of type III HH, justify the diversity of their characteristics depending on whether they originate from type I or type II HH.

Materials and methods. The study included 126 patients with HH, including 87 type III hernias and 39 type I hernias, who underwent elective laparoscopic hernioplasty. The study consisted of several steps. In the first step, an assessment of the results of endoscopic examination in patients with type III HH was conducted to determine the diversity of the obtained data and the feasibility of dividing patients into subgroups using a two‑stage cluster analysis. In the second step, the subgroups obtained through cluster analysis were compared between themselves and with the patients with type I HH to determine the similarities or differences in endoscopic findings and clinical symptoms.

Results. Cluster analysis identified two clusters of indicators with a strong degree of association and differentiation. The main factor in the differentiation into clusters was the relationship between the gastroesophageal junction (GEJ) and the upper border of the HS (hernia sac) in an inversion. Based on this criterion, type III HH can be divided into two subgroups: type IIIA, where the GEJ is located proximally or at the same level as the highest point of the HS, and type IIIB, where the GEJ is located distally to the highest point of the HS. The occurrence of most endoscopic symptoms of HH in subgroup IIIA, in contrast to IIIB, did not significantly differ from type I HH, except for the shorter length of the esophagus and the greater axial length of the hernia. Additionally, patients with the IIIA HH subtype were almost indistinguishable from those with type I HH in terms of clinical characteristics, except for a higher average age and the occurrence of dyspnea. In subtype IIIB, compared to type I, symptoms related to gastroesophageal reflux were significantly less frequent, while symptoms indicative of impaired food evacuation were more frequent. The observed similarity between the endoscopic and clinical manifestations of type I and subtype IIIA HH suggests a common origin for these conditions. On the other hand, subtype IIIB, which differs in endoscopic and clinical indicators from type I and subtype IIIA HH, is evidently the result of the progression of type II HH.

Conclusions. Patients with type III HH exhibit significant diversity in clinical and endoscopic manifestations, which is attributed to the different origins of the HH (from type I or type II). An endoscopic feature indicating the hernia’s origin is the position of the GEJ relative to the highest point of the HS: below it corresponds to type II HH (62.1%), while at or above it corresponds to type I HH (37.9%).