How To: Best Test For Hiatal Hernia, GERD, Acid Reflux
Suppose you are dealing with heartburn, regurgitation, or other persistent symptoms. In that case, you are likely wondering how to test for acid reflux, GERD, hiatal hernia, and what each test actually tells you. Below, I outline the standard diagnostic options, what they show, and the limitations you should know about so you can make informed care decisions.
Barium swallow (Upper GI series)
The barium swallow is a traditional test. You drink a contrast called barium that coats the lining of the esophagus and stomach so they show up on X-ray. It helps visualize the stomach on chest images and can reveal a hiatal hernia when present.
Keep in mind that smaller hernias often yield false negatives on a barium swallow, so a normal study does not always rule out a hiatal hernia.
Standard chest x-ray
A routine chest X-ray taken P to A sometimes shows a hiatal hernia. It is fast and widely available, but it is not the preferred or most sensitive test for diagnosing a hiatal hernia.
CT scan
Computed tomography produces more detailed cross-sectional images of the chest and abdomen. CT can identify anatomy and larger hiatal hernias and is useful when clinicians suspect other chest or abdominal problems.
Esophageal manometry
Manometry measures pressure and muscle contractions along the esophagus. It does not directly show a hernia but evaluates esophageal function and the lower esophageal sphincter, which can influence symptoms and management.
Esophageal pH monitoring
pH testing uses a small probe placed in the esophagus to measure acidity over time. This helps determine whether your symptoms are due to acid reflux and the severity of reflux. It is handy when symptoms and endoscopy results do not match.
Endoscopy and its limitations
Endoscopy lets a physician look directly at the esophagus and stomach lining. It is performed in many patients with reflux symptoms, but it often yields false-negative results for hiatal hernia. Visualizing a small sliding hernia can be difficult, even with direct inspection.
Questionnaires and symptom assessments
Validated questionnaires such as GERD Q and GERD-HRQL help quantify symptom severity and are widely used in clinical practice. Online assessments can guide whether further testing is appropriate.
Putting it together: what to expect
No single test is perfect. Small hiatal hernias are frequently missed on imaging and endoscopy, and many cases of acid reflux and GERD are caused by a hiatal hernia even when tests come back negative. A combination of symptom assessment, functional testing, and imaging gives the best clinical picture.
Practical tips
- Start with a symptom assessment and discuss with your clinician which tests are appropriate for your case.
- If imaging is routine but symptoms persist, consider esophageal pH monitoring or manometry, or have the natural osteopathic hiatal hernia maneuver done and monitor symptoms.
- Remember that testing can yield false-negative results; persistent symptoms warrant reevaluation.
FAQ
Which test is best for diagnosing a hiatal hernia?
There is no single best test. Barium swallow, CT, and endoscopy can show hernias, but small sliding hiatal hernias are often missed. Functional tests, such as pH monitoring and manometry, help assess reflux and esophageal function when imaging is inconclusive.
Can a routine endoscopy rule out a hiatal hernia?
No. Endoscopy frequently yields false-negative results for hiatal hernias, especially smaller ones. Clinical symptoms and other tests should be considered.
Does a hiatal hernia cause most acid reflux?
Many cases of acid reflux and GERD are related to hiatal hernia, but reflux can also occur without a hernia. Testing helps determine the cause and severity.
When should I get pH monitoring?
Consider pH monitoring when symptoms persist despite treatment, when endoscopy is routine but reflux is suspected, or before specific procedures to quantify acid exposure.
Are there reliable self-assessments for reflux and hiatal hernia?
Validated questionnaires, such as the GERD Q and GERD-HRQL, are commonly used to assess symptom severity and guide next steps. Still, they do not replace clinical evaluation and testing.