Functional disturbance in hiatal hernia in infants and children

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Abstract
Retrograde flow from the stomach into the esophagus in infants and children is prevented by the mucosal choke and muscle cuff of the normally located esophageal vestibule. When a hiatal hernia is present the cardinal functional abnormality is the retrograde flow of gastric content into the esophagus. The important anatomical features are the location of the esophageal vestibule in the thorax, the phreno-esophageal membrane with its attachment to both the diaphragm and the vestibule, and the size of the hiatus in the diaphragm. When the esophageal vestibule lies entirely in the thorax its whole length lies in a zone of subatmos-pheric pressure. Reduction in tension in the muscle cuff following a dry swallow may also result in vestibular opening with retrograde flow. Inefficient secondary stripping waves may fail to empty the re-fluxed gastric content from the esophagus, permitting peptic esophageal vestibule, because of tension in the abnormally located phreno-esophageal membrane, are considered. The paradox of free retrograde flow with a small hernia and small retrograde flow with a large hernia is resolved. Basic radiological criteria for establishing the diagnosis of hiatal hernia in this age group are given. The objectives of surgery and the means by which they may be achieved are discussed.