Hiatus hernia differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Overview

Hiatus hernia presents as gastroesophageal reflux disease (GERD) with dysphagia and must be differentiated from other causes of dysphagia.

Differentiating hiatus hernia from other diseases

Disease Signs and Symptoms Barium esophagogram Endoscopy Other imaging and laboratory findings Gold Standard
Onset Dysphagia Weight loss Heartburn Other findings Mental status
Solids Liquids Type
GERD

/Hiatus hernia

Gradual or

sudden onset

+ - Progressive ± + Normal
Esophageal stricture Gradual or sudden + - Progressive ± ± Normal
  • Sacculations
  • Fixed transverse folds
  • Esophageal intramural pseudodiverticula   
Esophageal web Gradual + +/- Progressive - ± Normal
  • Smooth membrane not encircling the whole lumen
Plummer-Vinson syndrome Gradual + - Non progressive ± - Normal

Triad of

Diffuse esophageal spasm Sudden + + Non progressive + + Normal
  • Nonperistaltic and nonpropulsive contractions
  • Corkscrew or rosary bead esophagus
  • Inconclusive
Achalasia Gradual + + Non progressive ± - Normal
  • "Bird's beak" or "rat tail" appearance
  • Dilated esophageal body
  • Air fluid level (absent peristalsis)
  • Absence of an intragastric air bubble
  • Residual pressure of LES > 10 mmHg
  • Incomplete relaxation of the LES
  • Increased resting tone of LES
  • Aperistalsis
Systemic sclerosis Gradual + + Progressive ± + Normal
  • Dysmotility
  • Peptic stricture (advanced cases)
Positive serology for
Zenker's diverticulum Gradual + - ± - Normal
  • Exclude the presence of SCC 
  • CT & MRI shows out-pouching over the posterior esophagus in the Killian's triangle
Esophageal carcinoma Gradual + + Progressive + ± Normal
  • CT and PET scan is an optional test for staging of the disease
Stroke

(Cerebral hemorrhage)

Sudden + + Progressive + ± Impaired
Motor disorders

(Myasthenia gravis)

Gradual + + Progressive ± Normal
  • Stasis in pharynx and pooling in pharyngeal recesses
  • Anti–acetylcholine receptor antibody test

References

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