CLINICAL RESEARCH Clinical Utility of Endoscopy and Barium Swallow X-Ray in the Diagnosis of Sliding Hiatal Hernia in Morbidly Obese Patients: A Study Before and After Gastric Bypass Fernando Fornari & Richard Ricachenevsky Gurski & Daniel Navarini & Victor Thiesen & Luis Henrique Barbosa Mestriner & Carlos Augusto Scussel Madalosso Received: 23 February 2009 / Accepted: 28 August 2009 / Published online: 12 September 2009 # Springer Science + Business Media, LLC 2009 Abstract Background The main clinical consequence of sliding hiatal hernia (SHH) is gastroesophageal reflux disease (GERD). Endoscopy and barium swallow X-ray are commonly used to diagnose SHH. We aimed to assess the clinical utility of endoscopy and X-ray in the diagnosis of SHH in morbidly obese patients before and after gastric bypass (GBP). Methods Ninety-two patients underwent reflux symptoms evaluation, upper gastrointestinal endoscopy, and barium swallow X-ray before and 6 months after banded GBP. The performance of endoscopy in diagnosing SHH was assessed, taking X-ray as reference. Endoscopy and X-ray were tested as predictors of SHH with GERD. Results SHH was more prevalent when characterized by X- ray than endoscopy either before (33% vs. 17%; P=0.017) or after GBP (26% vs. 7%; P=0.001). Endoscopy showed low sensitivity (≤40%) and high specificity (≥94%) in diagnosing SHH. Before GBP, more patients with SHH had GERD compared to patients without SHH using either X- ray (83% vs. 58%; P=0.016) or endoscopy (94% vs. 61%; P =0.009). After GBP, only patients with radiologic evidence of SHH showed higher prevalence of GERD compared to patients without SHH (50% vs. 26%; P= 0.037). SHH patients also reported weekly or daily vomit more often than patients without SHH (59% vs. 32%; P=0.026). Conclusions In morbidly obese patients, X-ray is superior to endoscopy in diagnosing SHH either before or after banded GBP. In patients treated with this technique, the utilization of X-ray may help in the management of reflux symptoms and frequent vomit. Keywords Morbid obesity . Gastroesophageal reflux disease . Hiatal hernia . Endoscopy . X-rays Introduction Sliding hiatal hernia (SHH) refers to a condition in which the proximal stomach herniates through the esophageal hiatus of the diaphragm into the mediastinum. The main clinical consequence of SHH is gastroesophageal reflux disease (GERD) [1,2], clinically manifested either by reflux symptoms such as heartburn and acid regurgitation or by reflux esophagitis [3]. In the scenario of GERD, SHH may contribute to the failure of the antireflux barrier and compromising of the esophageal clearance, resulting in increased exposition of the esophagus to reflux of gastric contents [4–6]. F. Fornari (*) : D. Navarini : C. A. S. Madalosso GASTROBESE, Rua Uruguai, 1555, 1° andar, 99010112 Passo Fundo, Rio Grande do Sul, Brazil e-mail: fernandofornari@gmail.com F. Fornari : L. H. B. Mestriner : C. A. S. Madalosso Hospital de Ensino São Vicente de Paulo, Passo Fundo, Brazil F. Fornari Faculdade de Medicina, Universidade de Passo Fundo, Passo Fundo, Brazil R. R. Gurski : D. Navarini : V. Thiesen : C. A. S. Madalosso Programa de Pós-Graduação em Cirurgia, UFRGS, Porto Alegre, RS, Brazil OBES SURG (2010) 20:702–708 DOI 10.1007/s11695-009-9971-y