Simultaneous cineradiographic-manometric study of the distal esophagus: small hiatal hernias and rings

Manometric features were correlated with roentgen configurations of the esophagogastric region in subjects with hiatal hernias and with rings by simultaneous cineradiographic and manometric study. The supradiaphragmatic pouch in small hiatal hernias was shown to have two functionally distinct components. Its upper portion (vestibule) had sequential contractile motor activity in response to swallowing. The lower portion was inactive and represented the true hernial sac. A weblike ring (Schatzki) or notches were often identified at the junction of these two segments. There was no peristaltic activity at or below this type of ring. A broad ring with contractile radiological behavior at the upper margin of the vestibule showed resting high pressure which fell on swallowing. This differed from the resting high pressure zone of normals in being shorter in length and showing an abrupt rather than gradual transition to contiguous pressures. Retrograde barium flow from hernial sac into the tubular esophagus was not seen when such a contractile A-ring was evident. Retrograde barium flow into the esophagus from the hernial sac occurred in those subjects not having a resting high pressure zone. Such reflux was delayed as long as the peristaltic wave persisted in the vestibular segment above the hernial sac. A constriction above the hernial sac during retrograde flow presumably represents a residual manifestation of the peristaltic wave, is transient, and is not associated with elevated resting pressure. The pressure inversion point was inconstant in its location in hiatal hernia subjects. It was often located at the site of the upwardly displaced high pressure zone, although a second pressure inversion point could be identified at the hiatal level on deep inspiration.