This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and Sutab. Beyond the GE junction, we should be thinking about the type, the presence and the type of a hiatal hernia. And again, this is just a simple cartoon wherein normally the GE junction and the diaphragmatic hiatus is actually present distal to the diaphragm. Now, we have some certain types of hiatal hernias that we should all be recognizing. So the most common is the sliding type of hiatal hernia, also called a type 1 hiatal hernia, where the GE junction is proximally displaced from the diaphragmatic hiatus. And this part of the gastric, of the stomach will just be sliding in and out depending on the interthoracic pressure. Now, type 2 hiatal hernia is wherein the GE junction is still at the level of the diaphragmatic hiatus, but a portion of the stomach, which is usually the fundus, is now proximally herniated above the level of the diaphragm. Now, this would be called a parasophageal hernia or a type 2 hernia. What is a type 3 hernia? A type 3 hernia is when you have both of these components. So the GE junction is proximally displaced and the part of the stomach is also above in a parasophageal manner, herniated above the diaphragm. And then in this picture, this is, again, a combination of cartoons. These are barium swallows, and then these are the endoscopic correlates. And here you have a sliding hernia. And this is something that you can usually see very clearly on endoscopy. This is a type 2 parasophageal hernia where you are seeing the portion of the gastric fundus. The GE junction is actually still located at the level of the diaphragmatic hiatus. And here you can see the opening in the endoscopy of the parasophageal hernia sac. Type 3 is where you not only have proximal displacement, but also the herniated fundus. And again, this is something that you can see on retroflex view very carefully. And then what is type 4? Type 4 is a parasophageal hernia where intra-abdominal contents, this can be the colon or maybe the omentum, is now also herniated above the level of the diaphragm. And this typically will require some degree of surgical correction. You may have also heard of the HILT classification. This is also available in some of the endoscopy reporting softwares and allows us to quote unquote grade the GE junction and may have an impact on the type of therapeutic options that we might present to the patient. So a grade 1 GE junction is a HILT classification is where on retroflex view, the GE junction is snug against the endoscope. So this is an intact GE junction with all three components typically being at the same level. And there is no opening of the GE junction in the respiratory cycle. Now grade 2 is where in this ridge or the angle of kiss is a little bit more lax. And this typically will happen only during respiration. And the ridge is less well-defined and it opens with respiration. Grade 3 is where in now you're beginning not only to see this laxity of the GE junction, but now you're beginning to see some proximal displacement of the GE junction and the ridge is affected and the hiatus now is becoming patchy. So this is an early stage hiatal hernia. And then of course, grade 4 is where in now you have a large hernia, a substantial hernia with proximal displacement of the GE junction and a sliding hiatal hernia. And then this is something that you can easily see and the hiatus is wide open at all times. So this would be grade 4. Also important to get an idea of, identify and get a sense of if the patient has had any antireflux surgery. And there are several kinds of antireflux surgery, as we know, the commonest is a nascent fundoplication, which is a 360 degree wrap, wherein a part of the fundus is wrapped all around the esophagus. And if you have an intact fundoplication, this is typically what you should be seeing. You should clearly be seeing the nipple valve, which is the impact of the fundus being wrapped around the stomach. And then you should clearly be seeing an anterior groove and a posterior groove. And you can see that the wrap is snug around the endoscope. So this would be an intact nascent fundoplication. A toupee fundoplication is a 270 degree wrap. So you are wrapping about three quarters of the circumference. And this might be done for a variety of reasons, perhaps in patients who may have some compromise in their esophageal motility. And in this instance, you are not going to see a full wrap, but indeed what is typically or classically described is an omega shaped wrap, wherein you have a posterior groove, you have the valve itself, and then you have the anterior groove. A door fundoplication is an anterior fundoplication, which is only a 180 degree wrap, again, done for perhaps compromise esophageal motility. And in this instance, you are not going to see a posterior groove, but you are only going to see an anterior groove, as you can see in this endoscopic picture. So this would be the best description of an intact door fundoplication. So this is a nascent fundoplication. This is panel A. This is a toupee fundoplication, which is 270 degrees. And this would be an anterior fundoplication or a door fundoplication. Now, oftentimes you are going to see failed antireflux procedures. So again, this would be an example of what a loose wrap is looking like. The folds are no longer radiating. They are basically just loosely wrapped around the GE junction. You may have a recurrent parasophageal hernia. You can still see portions of the fundoplication here. And then, of course, in this instance, the wrap has really not only become loose, but is also associated with a recurrent sliding hernia. So those are some findings that we have to be able to evaluate and then also report, because these may have implications on our management. Coming to the end of the talk, do not forget to see Cameron's erosions, which are basically erosions or ulcers at the level of the diaphragmatic hiatus. And these might be the only findings you might see in patients with iron deficiency anemia. And then as you're coming back, you may want to pay attention as well to the upper esophageal sphincter. Look carefully for any narrowing in patients with proximal dysphagia. Look for a cricopharyngeal bar or a stricture. And of course, we would see inlet patches as well, and pay some attention to this as you are withdrawing. So to conclude, the keys to a thorough esophageal exam are to identify and document the landmarks as we talked about. Look for signs of eosinophilic esophagitis if dysphagia is a symptom. Do consider biopsying, even if there is no endoscopically evident cause. Use the Los Angeles classification system for grading esophagitis. Assess carefully for the presence or absence of barracks. Examine and sample any visible lesions. Avoid biopsying an irregular Z-line. And last but not the least, retroflex carefully. Thank you so much. Thank you.

hiatal hernias

HILT classification

antireflux surgeries

endoscopy

esophageal exam