Examinations

If reflux symptoms persist over a prolonged period or recur after discontinuation of medical therapy, a structured diagnostic evaluation is recommended.

Upper endoscopy (gastroscopy) is central to the diagnostic evaluation. This allows direct assessment of inflammatory changes, Barrett’s mucosa, and the presence of a hiatal hernia. If indicated, tissue samples (biopsies) are obtained to allow for a more detailed evaluation of the mucosa.

For a functional assessment of the junction between the esophagus and the stomach, as well as the esophagus as a whole, additional testing may be required depending on the clinical situation.

A key role may be played by 24-hour esophageal pH monitoring. Using a thin catheter, acid exposure within the esophagus is measured. Alternatively, prolonged monitoring over 48 hours can be performed using a small capsule (e.g., Bravo Capsule). This allows objective quantification of the frequency, duration, and extent of acid reflux.

If necessary, esophageal manometry is performed. This test measures esophageal motility and coordination and is particularly important prior to surgical treatment, as impaired function must be taken into account when selecting the appropriate surgical approach.

In selected cases, additional radiologic evaluation of the esophagus with contrast medium may be performed. This allows assessment of swallowing dynamics, esophageal function, and the passage of contrast into the stomach and upper small intestine.
If required, the examination may be supplemented with solid food (e.g., bread or rusks) in order to assess function under more physiologic, real-life conditions.
This is particularly helpful in cases with inconclusive findings, complex clinical situations, or after previous surgery, providing additional important diagnostic information.

These diagnostic tests enable an objective assessment of reflux disease and form the basis for an individualized treatment strategy.

Gastroscope

Hiatal Hernias: Classification

The illustrations below demonstrate the different types of hiatal hernias and their characteristic anatomical features. For comparison, the final illustration shows the anatomical appearance following successful reconstruction using our modified BICORN procedure.

Normal Anatomy

Type I – Sliding Hiatal Hernia

Type II – Paraesophageal Hiatal Hernia

Type III – Mixed Hernia

Type IV – Complex Hernia

Status post Modified BICORN Procedure:

Endoscopic Findings in Reflux Disease

Upper endoscopy (gastroscopy) is one of the most important investigations when gastroesophageal reflux disease (GERD) or a hiatal hernia is suspected. It provides valuable information about the esophagus, gastroesophageal junction, stomach, and duodenum.

It is important to understand that symptoms and objective findings do not always correlate. Some patients with large hiatal hernias experience little or no reflux symptoms, while others may suffer from severe reflux symptoms despite having no hiatal hernia or only a very small one. Likewise, the severity of reflux symptoms often does not reflect the grade of esophagitis seen.

The following images illustrate common endoscopic findings that may be encountered in patients with reflux disease.

Los Angeles Classification (LA Classification)

The severity of reflux esophagitis is usually assessed using the Los Angeles Classification (LA Classification). It is the internationally accepted standard for grading inflammatory changes of the esophagus seen during upper endoscopy.

Normal Finding: