Although a barium-contrast radiography originally constituted the first development in diagnosing hiatal hernia (HH) and gastroesophageal reflux,
nowadays conventional radiology is no more an accurate investigation for their assessment.
Paradoxically,
we noticed a tendency to a negative contribution to the management of these conditions.
In fact,
we observed in clinical practice a worrisome rate of HH reported as incidental extra-colonic finding during CT with water enema (CT-WE) and CT colonography (CTC).
This suspicious has been recently confirmed by the study of Pickhardt et al.,
which demonstrated a trend of overestimation of the hiatus hernia dimensions and a not entirely negligible number of misdiagnosed cases [1].
A deductive explanation is that colon distention induced by water or gas perfusion/delivery increases intra-abdominal pressure,
thus favouring a transitory displacement of the cardias and partially the stomach through the diaphragm into the thorax,
defined as “sliding” or “type I” HH [2].
As a fact,
it has been already demonstrated that abdominal obesity by increasing intra-abdominal pressure promotes reflux and the development of hiatus hernia [3].
Hiatal hernia is a well known factor impacting on most mechanisms underlying gastroesophageal reflux (low sphincter pressure,
transient lower oesophageal sphincter relaxation,
oesophageal clearance and acid pocket position),
explaining its association with more severe disease and mucosal damage [4-6].
These latter in turn,
are related with the risk of complications such as erosive esophagitis,
Barrett´s esophagus and ultimately,
esophageal adenocarcinoma [7,
8].
Therefore,
although HH itself is a not life-threatening condition its diagnosis may induce on patients,
often not correctly instructed,
worries and psychological distress that notably impact on quality of life.
Moreover,
several studies have demonstrated a bi-directionally cause-effect interrelationship between upper gastrointestinal symptoms and psychological distress [9].
As a consequence of that,
an erroneous diagnosis of a fictional disease may potentially lead to a true functional disorder.
This latter,
above all GERD and dyspepsia,
deeply bear upon the socio-sanitary costs by increasing utilization of healthcare resources (i.e.
frequent visits to physicians,
long-term medications use,
redundant invasive expensive investigations) and reducing work productivity (i.e.
absenteeism and presenteeism) [10,
11].
These costs are even more inadequate if led by a initial misdiagnosis.
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The search for the presence of HH should then be limited on subjects with typical manifestations - such as epigastric pain,
belching,
heartburn and regurgitation,
especially when refractory to treatment or when alarm signs are present.
Whenever possible,
the diagnosis and estimation of the hernia,
should be assessed by reference standard methods,
such as esophageal manometry or even high-resolution manometry.
This investigation provides further information,
particularly for type I HH,
and is mandatory in case surgical treatment is considered [12-14]. Therefore,
it is our opinion that an erroneous reporting of HH may trigger a consecutive diagnostic process that is not only unnecessary,
inducing a unmotivated anxiety in the patient,
but also expensive and time-consuming for both the patient and the healthcare system [15].
As a consequence,
the purposes of our study were to determine whether colonic distention at CT-WE and CTC can induce a small incidental physiologic sliding hiatal hernias and to detect if hiatal hernias size modifications could be considered significant for both water and gas distention techniques.