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Identifying the LES when a Hiatal Hernia is Present using HRiMOne of the many advantages of our High Resolution Esophageal Manometry System (probe and software) is excellent visualization of the probes position in the esophageal body. Because there are 32 pressure sensors we can appreciate the esophageal length often from pharynx to stomach using ClouseVIEW (color contour mapping). Because of this comprehensive view of the esophageal body, when a hiatal hernia is evident, we can easily appreciate the difference between the diaphragm and the LES. The probe can then be properly placed with the reference line at the sphincter so LES relaxation can be measured.A patient may come in with a diagnosis of hiatal hernia. This does not mean it will be visualized during a HRiM procedure. They may have a sliding hernia meaning that it is sometimes reduced into normal position with the diaphragm and LES in the same location. This may especially be true during this procedure as the patient is asked to be NPO and therefore does not have gastric distention, which could displace the hernia. However, if a separation of the diaphragm and the LES is seen - BONUS! (See picture)During post-procedure review of a study, when evaluating for the presence of a hiatal hernia, we look for the PIP - Pressure Inversion Point (the diaphragm). Below this point is the positive-pressure abdominal cavity. Above this point is the negative-pressure thoracic cavity. Hence, the inversion of the pressure waves from positive with inspiration to negative with inspiration as you scan the waves from stomach up through the LES area.In normal anatomical position, the PIP is at or below the proximal edge of the LES. A small hiatal hernia may be indicated when the PIP is below the HPZ. A larger hiatal hernia is evident when the PIP is below the distal edge of the LES. The distance between the PIP and the distal edge of the LES represents the amount of stomach that has been pushed up into the abdominal cavity.A value included on your report in the LES Profile Section along with the LES length (normal 3cm) is the intra-abdominal LES length. In the normal anatomical position at least 1 cm of the LES should be below PIP. When a hiatal hernia is present, the intra-abdominal length will be shorter and may even be negative. For example, when the entire LES plus 3 cms of stomach have been displaced above PIP, the intra-abdominal length will be reported as - 3.What does a hiatal hernia look like in ClouseVIEW? The diaphragm shows as a band of round or oval dots of pressure with each inspiration. This leads to a pattern on the Clouse plot that can resemble a beaded necklace that has been laid out flat. This band can run at the same level as the LES (normal anatomical position) or below the LES (hiatal hernia). If the diaphragm is at or just under the LES, this inspiration pattern may seem to relax with the LES. If the diaphragm is well below the LES as in a moderate to large hiatal hernia, the diaphragm pattern changes little during a swallow.When two horizontal lines of increased pressure are seen in the area at the bottom of a swallow, the LES will always be above the diaphragm. (See picture) This upper band is the one to be placed on the reference line. Do not confuse these two bands with a band of cardiac artifact somewhere in the esophageal body area that pulses at a much faster rate than the respirations. Another good indication that you have picked the correct band of color is that the peristaltic wave will pass through cardiac artifact ending at the LES and not continue on to the diaphragm. During placement, a test swallow can be given. Where the propagation stops and the peristaltic wave appears to turn to the right, this is the LES. It will look like a leg turning into a foot.If the peristalsis is weak, consider giving a wet test swallow as these often show more obvious pressure than do dry swallows. Also, if the colors in the distal esophagus and LES are weak, consider changing the color scale using the scale on the left. Changing this scale only changes your view and not the patient data. Click and drag the top tab to 100 mmHg or lower. This will intensify the red colors and make visualization of the LES easier.What should I do if I missed the LES and put the diaphragm on the reference line instead? If you missed the LES we can shift the channels to the correct position in editing. Contact our Clinical Education department and we can assist with this process. Also, if you should miss the LES and realize part way into the study that you placed the reference line on the diaphragm instead of the LES, you have two options. 1. Stay where you are and complete the study. The study can be shifted during editing to analyze the correct channels 2. If only a few swallows have been done in the incorrect position, consider pulling the pro