James M Tatum, MD, Evan Alicuben, MD, Nikolai Bildzukewicz, MD, Kulmeet Sandhu, MD, Kameran Samakar, MD, Caitlin Houghton, MD, John L Lipham, MD. Keck School Of Medicine Of The University Of Southern California
Introduction: Hypotension of the lower esophageal sphincter (hLES) and the presence of hiatal hernia (HH) have both been associated with gastroesophageal reflux disease (GERD). The exact likelihood with which a hLES or a hiatal hernia predict GERD continues to be defined. We hypothesize a synergistic interaction in those with hLES and HH in predicting GERD as defined by a positive pH study.
Methods and Procedures: Between 2012 and 2013, 148 consecutive patients presenting to a surgical practice with symptoms most concerning for GERD, without prior antireflux surgery were evaluated by high resolution manometry (HRM), esophagogastroduodenoscopy (EGD), videoesophagography (VEG) and an ambulatory pH study. hLES was defined as residual LES pressure of <15mmHg, HH was defined as having been noted and measured by the radiologist, these were further categorized into any HH, 1-3cm, >3-5cm or >5cm. Hill grades III and IV were used to define laxity of the LES as measured on insufflated endoscopy. A positive diagnosis of GERD is defined as a daily or composite DeMeester score of >14.72 on 24 or 48-hour ambulatory pH study. Data were analyzed using SPSS (SPSS Inc.) to calculate test characteristics including Fisher exact test and likelihood ratios.
Results: Prevalence of a +pH study was 61% (90/148) patients in this study. hLES alone did not significantly predict a + pH test (63% prevalence in those with a hLES vs. 52% in those with normal LES), (p=0.47). Patients with any HH had a 73% probability of GERD, with a likelihood ratio (LR) of 1.68 [95% CI: 1.13-2.17], p=0.001. A hLES with any hiatal hernia carried a 75% probability of a +pH test with a 1.94 [1.28-2.93], p=0.001. This relationship was strongest with a hLES and HH of 1-3cm in size, LR 1.99 [1.21-3.29], p<0.01. Hill grade III/IV valve was only significantly associated with a + pH test (81%) when combined with a hLES and a HH of 1-3cm, LR 2.18 [1.04-4.54], p=0.02.
Conclusion: Hypotension of the LES alone did not predict GERD in this population while the presence of any HH did. The association between HH and GERD is strongest when hLES is present. Therefore, GERD is a disease caused by both a hypotensive LES and compromised integrity of the diaphragmatic hiatus. This conclusion has important implications in the surgical approaches to GERD.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87422
Program Number: P403
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
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