Skip to content
How It Works
Explore
Ask a Question Resources Pricing
Who It's For
Patients
Decode results, prep for appointments, weigh options.
Caregivers & advocates
Carry the research load for someone you love.
Providers & clinicians
Resources for patients in your practice.
Log In Sign Up
PubMed This is a summary of 21 peer-reviewed journal articles Updated
Hiatal Hernia

Decoding Your Diagnostic Tests and Medical Reports

At a Glance

Hiatal hernia diagnosis may require more than one test: endoscopy examines the lining, a barium swallow shows the hernia’s shape, manometry assesses muscle function, and pH monitoring measures reflux. Report grades and measurements help explain the findings.

Diagnosing a hiatal hernia is rarely a “one-and-done” process. Because the stomach can slide in and out of the chest, a single test might miss it or underestimate its size [1][2]. To get a complete picture, doctors use a toolkit of complementary tests that look at your anatomy, your muscle function, and the actual acid levels in your food pipe [3].

Important: Endoscopy, barium studies, and manometry evaluate gastrointestinal causes of chest pain; they do not rule out cardiac issues. Always seek emergency cardiac assessment for new, unexplained, severe, or exertional chest pain.

The Diagnostic Toolkit

Your medical team may use several different tests to rule out “look-alikes”—such as achalasia (a rare condition where the esophagus cannot move food down)—and to plan the best care for you [4][5]. Note that not every patient needs every test; manometry and reflux monitoring are often used for selected patients or for preoperative planning.

  • Upper Endoscopy (EGD): A tiny camera is used to look inside your esophagus and stomach. This is a key test for checking for damage like esophagitis (inflammation) or Barrett’s esophagus (cell changes from chronic acid exposure, which requires tissue biopsies during the endoscopy to diagnose) [6][7].
  • Barium Swallow (Esophagram): You drink a chalky liquid while X-rays are taken. This “action movie” of your anatomy is excellent for seeing the physical shape of a hernia and identifying if the stomach is twisting (volvulus) [8][9].
  • High-Resolution Manometry (HRM): A thin tube measures the pressure of your esophageal muscles as you swallow. This is one way to see if your lower esophageal sphincter (LES) and your diaphragm have moved apart [10][11]. Doctors often look for a separation of more than 2 centimeters as a suggestive finding of a hernia, which must be interpreted alongside other imaging [3].
  • pH Monitoring: A small sensor measures how much acid is backing up into your esophagus over 24 to 48 hours. If acid exposure time is greater than 6% when performed off PPI therapy, it provides conclusive evidence of GERD, even if your endoscopy looks normal [12][13].

Decoding Your Medical Report

Medical reports are filled with shorthand and grading systems. Knowing these terms can help you understand the severity of your condition and how it is changing over time.

The Hill Grade (The Flap Valve)

During an endoscopy, doctors look back at the “flap valve” where the esophagus enters the stomach. They use the Hill Grade (I through IV) to describe how well this valve is working [14].

  • Grade I: A prominent fold of tissue creates a tight seal.
  • Grade IV: No fold is present, and the opening (hiatus) stays wide open around the camera, often revealing a hernia [14].
    (Note: Hill grade has limited reliability and is not, by itself, a definitive measure of long-term prognosis.)

The Los Angeles (LA) Grade (The Damage)

If the hernia is causing acid reflux, your esophagus might be irritated. This is graded based on the extent and continuity of mucosal breaks:

  • LA Grade A: Mild, small breaks in the lining.
  • LA Grade D: Severe mucosal breaks that involve at least 75% of the esophageal circumference [6][12].

Measurements to Look For

  • Axial Length: This is the “height” of the hernia, typically measured as the distance between the diaphragmatic pinch and the gastroesophageal junction [14].
  • Z-line or SCJ: This is the squamocolumnar junction, where the esophagus lining meets the stomach lining. Its position relative to your diaphragm helps define the hernia [15][16].
  • Prague Classification: If you have Barrett’s esophagus, you will see “C” and “M” numbers (e.g., C2 M4). These track the length and circumference of the affected area [15].

The Completeness Checklist

A thorough medical report should provide more than just a “yes” or “no” for a hernia. While not every report requires every detail, examples of data that may be on the report include:

  1. Anatomical Landmarks: The exact distance (in centimeters from your teeth) to the junction of the stomach and the diaphragm [17].
  2. Hernia Type: A clear classification (Type I, II, III, or IV) [18].
  3. Muscle Function: From your manometry, a measurement of Integrated Relaxation Pressure (IRP) to help evaluate for achalasia [19][20].
  4. Mucosal Health: Specific notes on whether there are ulcers (Cameron erosions), strictures (narrowing), or food retention [7][20].
  5. Percentage of Herniation: For large hernias, a note on how much of the stomach (e.g., “30% of gastric contents”) is in the chest [21].

Common questions in this guide

What tests are used to diagnose a hiatal hernia?
Doctors may combine an upper endoscopy, barium swallow, high-resolution manometry, and pH monitoring. Endoscopy checks the lining, barium imaging shows the hernia’s shape, manometry measures muscle pressure, and pH monitoring measures acid exposure. Not every patient needs every test.
What does a hiatal hernia endoscopy look for?
An upper endoscopy uses a camera to examine the esophagus and stomach. It can identify inflammation, Barrett’s esophagus, ulcers such as Cameron erosions, narrowing, or retained food; Barrett’s esophagus requires tissue biopsies for diagnosis. Endoscopy can also help assess the flap valve using the Hill grade.
What do Hill grade and LA grade mean on an endoscopy report?
Hill grade describes how well the flap valve at the esophagus-stomach opening closes: Grade I is a prominent tight fold, while Grade IV has no fold and a wide-open opening. LA grade describes the extent of reflux-related breaks in the esophageal lining, from mild Grade A to severe Grade D. Hill grade alone does not predict long-term outcome.
What does separation between the LES and diaphragm mean?
Manometry can measure the distance between the lower esophageal sphincter and the diaphragm. A separation greater than 2 centimeters may suggest a hiatal hernia, but doctors interpret it with other test results because it is not a stand-alone diagnosis. Manometry can also help evaluate achalasia and other movement problems.
Can I have reflux or a hiatal hernia if my endoscopy is normal?
Yes. A normal endoscopy may not show all hiatal hernias or reflux, especially because the stomach can move in and out of the chest. If symptoms continue, pH monitoring measures acid exposure over 24 to 48 hours, and pH-impedance testing may be considered when non-acid reflux is a concern.
What information should be included in a hiatal hernia report?
A useful report may document the distances to the gastroesophageal junction and diaphragm, the hernia type, and the amount of stomach in the chest. It may also include the Hill or LA grade, esophageal lining findings, and manometry measurements such as integrated relaxation pressure. The exact details vary by test and patient.
Can hiatal hernia tests rule out a heart problem causing chest pain?
No. Endoscopy, barium studies, manometry, and reflux monitoring evaluate gastrointestinal causes, not heart-related causes. New, unexplained, severe, or exertional chest pain requires emergency cardiac assessment.

Get notified when new evidence is published on hiatus hernia.

We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.

References

References (21)
  1. 1

    Diagnostic value of X-ray, endoscopy, and high-resolution manometry for hiatal hernia: A systematic review and meta-analysis.

    Li L, Gao H, Zhang C, et al.

    Journal of gastroenterology and hepatology 2020; (35(1)):13-18 doi:10.1111/jgh.14758.

    PMID: 31206788
  2. 2

    Discrepancies in the Reporting of Hiatal Hernia Size: A Review.

    Nehila T, Sher T, Ganam S, et al.

    The American surgeon 2025; (91(5)):877-886 doi:10.1177/00031348251329465.

    PMID: 40114474
  3. 3

    Reflections on surgery for hiatal hernia.

    Aiolfi A, Bona D, Wang Q, Bonavina L

    Updates in surgery 2026; (78(1)):1-8 doi:10.1007/s13304-025-02490-w.

    PMID: 41430014
  4. 4

    The Mexican consensus on non-cardiac chest pain.

    Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, et al.

    Revista de gastroenterologia de Mexico (English) 2019; (84(3)):372-397 doi:10.1016/j.rgmx.2019.05.002.

    PMID: 31213326
  5. 5

    [Pharmacological Treatments of Esophageal Dysphagia].

    Cho YK

    The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi 2021; (77(2)):71-76 doi:10.4166/kjg.2021.024.

    PMID: 33632997
  6. 6

    AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review.

    Yadlapati R, Gyawali CP, Pandolfino JE,

    Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2022; (20(5)):984-994.e1 doi:10.1016/j.cgh.2022.01.025.

    PMID: 35123084
  7. 7

    Comprehensive Assessment of Esophageal Disorders Associated with Hiatus Hernia: Insights from Big Data Analysis.

    Baker FA, Savarino E, Ahmad HS, et al.

    Dysphagia 2024; (39(4)):623-631 doi:10.1007/s00455-023-10642-6.

    PMID: 38285232
  8. 8

    Esophageal hiatal hernia: risk, diagnosis and management.

    Yu HX, Han CS, Xue JR, et al.

    Expert review of gastroenterology & hepatology 2018; (12(4)):319-329 doi:10.1080/17474124.2018.1441711.

    PMID: 29451037
  9. 9

    Gastric Volvulus: Diagnosis and Successful Endoscopic De-rotation Towards Conservative Management in a Patient With Multiple Comorbidities.

    Zafar M, Parvin J, Mcwhirter A, et al.

    Cureus 2022; (14(7)):e26862 doi:10.7759/cureus.26862.

    PMID: 35854951
  10. 10

    Chicago Classification update (v4.0): Technical review of high-resolution manometry metrics for EGJ barrier function.

    Kahrilas PJ, Mittal RK, Bor S, et al.

    Neurogastroenterology and motility 2021; (33(10)):e14113 doi:10.1111/nmo.14113.

    PMID: 33655610
  11. 11

    High-resolution manometry is superior to endoscopy and radiology in assessing and grading sliding hiatal hernia: A comparison with surgical in vivo evaluation.

    Tolone S, Savarino E, Zaninotto G, et al.

    United European gastroenterology journal 2018; (6(7)):981-989 doi:10.1177/2050640618769160.

    PMID: 30228885
  12. 12

    Modern diagnosis of GERD: the Lyon Consensus.

    Gyawali CP, Kahrilas PJ, Savarino E, et al.

    Gut 2018; (67(7)):1351-1362 doi:10.1136/gutjnl-2017-314722.

    PMID: 29437910
  13. 13

    Esophageal testing: What we have so far.

    de Bortoli N, Martinucci I, Bertani L, et al.

    World journal of gastrointestinal pathophysiology 2016; (7(1)):72-85 doi:10.4291/wjgp.v7.i1.72.

    PMID: 26909230
  14. 14

    American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: methodology and review of evidence.

    , Desai M, Ruan W, et al.

    VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy 2025; (10(2)):81-137 doi:10.1016/j.vgie.2024.10.001.

    PMID: 40012897
  15. 15

    Adequacy of EGD Reporting: a Review of 100 Reports from 100 Endoscopists.

    Boys JA, Azadgoli B, Martinez M, et al.

    Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2021; (25(5)):1117-1123 doi:10.1007/s11605-020-04634-2.

    PMID: 32607854
  16. 16

    Determining anatomical localisations of cervical oesophagus, hiatal clamp and oesophagogastric junction with oesophagogastroduodenoscopy.

    Bozdag E, Karaca Bozdag Z, Kurkcuoglu A, et al.

    Folia morphologica 2022; (81(3)):756-765 doi:10.5603/FM.a2022.0041.

    PMID: 35481704
  17. 17

    A novel endoscopic assessment of the gastroesophageal junction for the prediction of gastroesophageal reflux disease: a pilot study.

    Inoue H, Fujiyoshi Y, Abad MRA, et al.

    Endoscopy international open 2019; (7(11)):E1468-E1473 doi:10.1055/a-0990-9737.

    PMID: 31673619
  18. 18

    [Hiatus hernia : Standards and controversies in diagnostics and treatment].

    Weyhe D, Uslar V, Kühne J, Kluge A

    Der Chirurg; Zeitschrift fur alle Gebiete der operativen Medizen 2019; (90(4)):331-348 doi:10.1007/s00104-019-0932-2.

    PMID: 30903226
  19. 19

    Bridging the gap between radiologic and manometric criteria to diagnose esophageal motility disorders: a pictorial review for radiologists.

    El Sadaney AO, Codipilly DC, Bartlett DJ, et al.

    BJR open 2026; (8(1)):tzag005 doi:10.1093/bjro/tzag005.

    PMID: 41837237
  20. 20

    Updated Systematic Review of Achalasia, with a Focus on POEM Therapy.

    Cappell MS, Stavropoulos SN, Friedel D

    Digestive diseases and sciences 2020; (65(1)):38-65 doi:10.1007/s10620-019-05784-3.

    PMID: 31451984
  21. 21

    Complex hiatus hernias. Diagnostic and therapeutic management recommendations.

    Bruna M, Asunción Acosta M, Carbonell S, et al.

    Cirugia espanola 2026; (104(2)):800279 doi:10.1016/j.cireng.2026.800279.

    PMID: 41520825

This page explains hiatal hernia tests and report terms for education only and does not replace medical advice. Seek emergency care for new, severe, unexplained, or exertional chest pain, and ask your clinician to interpret your results.

Guide contents hiatus hernia
Research & Literature
02 Symptoms, Reflux, and Emergency Red Flags 04 Daily Management and Medical Treatments