Figure 20 - Concurrent manometric and videofluorographic recording of a 10-mL barium swallow in a subject with a reducing hiatal hernia characterized by late retrograde flow.

The tracings from the video images on the right correspond to the four selected times from the swallowing sequence indicated by the numbers at the top of the vertical lines intersecting the manometric record. The schematic diagram to the left indicates the relative spacing of the pressure sensing ports (side holes located proximal to the markers in the fluoroscopic images). The lines at the bottom of the tracing indicate the timing and direction of barium flow. Image 1 depicts the instant of swallowing when barium was visible only in the stomach. Image 2 depicts the instant the stripping wave was at the level of the most proximal sensor; the hiatal hernia had formed and sensors 2, 3, and 4 were in a common cavity within the hernia. Image 3 depicts when retrograde flow began, at which point sensors 2 and 3 were above the hernia, sensor 4 was measuring intrahernial pressure, sensors 5 and 6 were at the level of the diaphragm, and sensor 7 remained within the stomach. Image 4 shows residual barium in the distal esophagus and no hiatal hernia with sensors 3, 4, 5, and 6 now straddling the high pressure zone comprised of the LES and diaphragm. (Source: Sloan and Kahrilas,⁶⁶ with permission from American Gastroenterological Association.)