Endoscopic Correlation of Hiatal Hernia Size with the Severity of Reflux Oesophagitis (Los Angeles Classification): A Comprehensive Analysis of Clinical Symptoms and Mucosal Changes

– – Abdominal Tenderness (Yes vs. No) 2.120 1.145–3.925 0.017* *Statistically significant. Model adjusted for age. 5.0. Discussion of Results This study shows endoscopic evidence that hiatal hernia size is the key to reflux oesophagitis severity in this patient population. The highly significant positive correlation (p<0.001) between hiatal hernia size (?3cm) and Los Angeles (LA) classification of oesophagitis, especially LA Grade C, supports the anatomical disruption theory of GERD. 80.8% of patients with LA Grade C oesophagitis had hiatal hernias ?3cm, compared to much lower percentage of large hernias in LA Grades A and B. This is in line with the 'two-sphincter hypothesis' and previous studies that larger hernias more severely compromise the anti-reflux barrier at the gastro-oesophageal junction by reducing LES pressure and impairing oesophageal acid clearance (Kahrilas et al., 2008; Gordon et al., 2004). Our data suggests a clinical threshold of 3cm beyond which the risk of oesophageal mucosal injury increases exponentially. This is useful as it can guide endoscopic risk stratification and potentially flag patients with ?3cm hernias for more aggressive therapy or closer follow up (Liu et al., 2022; Bhardwaj et al., 2024; Stabilini et al., 2023). The association of specific symptoms with hiatal hernia size is more interesting. Larger hiatal hernias (?3cm) are significantly associated with regurgitation (p<0.001) but not heartburn. This is different from heartburn which did not show size-dependent variation in our cohort. Regurgitation may be more directly related to the volumetric and mechanical incompetence of the oesophagogastric junction caused by a larger herniated gastric pouch allowing easier retrograde flow of contents. Heartburn, while a hallmark of GERD, is influenced by a broader range of factors including oesophageal sensitivity, acid exposure duration and refluxate composition which may not be solely dependent on hernia size (Mayo Clinic, 2025; Kahrilas, 2025; Kahrilas, 2003). So, patients with prominent regurgitation should prompt a higher index of suspicion for a significant hiatal hernia and require endoscopic evaluation to assess hernia size and mucosal damage. This challenges earlier studies like Wallner et al. (2020) which said hernias <2cm are not related to symptoms, as our study shows a more complex relationship, especially in an African population where oesophageal sensitivity or other factors may be different (Ray-Offor & Falase, 2020). The strong association between increasing Body Mass Index , particularly obesity, and larger hiatal hernia sizes (p<0.001) corroborates existing literature (Louis et al., 1999; Weitzendorfer et al., 2017). Elevated intra-abdominal pressure due to visceral adiposity is a plausible mechanism, promoting gastric displacement and weakening of the phreno- oesophageal ligament (Timpson et al., 2024; Novo, 2021; Heymsfield & Wadden, 2017). This highlights obesity as a significant modifiable risk factor not only for hiatal hernia development but also for increased hernia size, which in turn, as our study shows, correlates with more severe oesophagitis. Furthermore, the finding that mucosal prolapse was significantly more frequent in patients with larger hernias (?3cm; p<0.001) underscores the mechanical consequences of substantial herniation. Mucosal prolapse can contribute to obstructive symptoms or intermittent dysphagia and represents another dimension of hernia-related pathology directly linked to its size. The endoscopic finding that 97.1% of patients with hiatal hernia in this symptomatic cohort also had reflux oesophagitis is remarkable, although this finding must be contextualized within a symptomatic population. It is also interesting that LA Grade C oesophagitis (56.3%), but not LA Grade D, occurred in our population. The difference seen may represent regional variation in the severity spectrum of disease, differences in referral protocols, differences in patient awareness to seek early treatment, or, more speculatively, inherent protective factors against extreme circumferential forms of oesophagitis (further study of GERD severity in African populations is required). The lack of strong evidence for an association between the size of a hiatal hernia and whether patients had bile reflux suggests that while bile reflux is part of the GERD complex, its presence is likely also related to duodenogastric motility function and the function of the pylorus; not merely the size and anatomical configuration of a hiatal hernia. Collectively, these results emphasize the clinical utility of precise endoscopic hiatal hernia sizing. Measuring the axial length of the hernia during endoscopy is a feasible and informative practice. Our data suggest that a hernia size of ?3cm serves as an important indicator of a higher likelihood of severe (LA Grade C) oesophagitis, the prominent symptom of regurgitation, and the presence of mucosal prolapse. These insights can aid clinicians in tailoring management, anticipating the need for more aggressive medical therapy, and making informed decisions regarding endoscopic surveillance or surgical consultation for patients with GERD and hiatal hernia. The findings also reinforce the importance of weight management as a potential strategy to mitigate the risk associated with larger hiatal hernias. 6.0. Conclusion This work has shown, with a high level of certainty, that endoscopically determined hiatal hernia size is an important predictor of the severity of reflux oesophagitis (as assessed by the Los Angeles classification) in patients presenting with dyspeptic symptoms. Endoscopically determined hiatal hernias ?3cm in length are strongly and significantly associated with more severe mucosal injuries, predominantly LA Grade C oesophagitis. Also of interest, there is a significant correlation between larger hernia size (?3cm) and regurgitation in the clinical history, and endoscopic finding of mucosal prolapse, while heartburn prevalence does not significantly depend on hiatal hernia size alone. Obesity also played an important role in the finding of larger hiatal hernias. These findings point to the clinical relevance of routine and accurate endoscopic measurement of hiatal hernia size. We would suggest this measurement should be routinely reported within the endoscopic evaluation of patients with GERD symptoms. A hiatal hernia of size ?3cm would represent a significant finding, which may require more aggressive medical management, closer follow-up and an evaluation for the possible application of anti-reflux surgery, especially in cases of severe oesophagitis or troublesome regurgitation. Future prospective longitudinal studies are needed to assess the natural history of hiatal hernias based on initial size, and the long-term patient outcomes and GERD complications from a management strategy which is outlined by size. Future studies should also be conducted in larger and more diverse populations to assess these relationships, and interventions such as weight loss which may alter hiatal hernia size and neuro-history of oesophagitis. 7.0. Ethical Considerations This research was performed according to the ethical principles in the Declaration of Helsinki. The Research and Ethics Committee of the University of Port Harcourt Teaching Hospital approved the research protocol (Reference: UPTH/ADM/90/S.II/VOL.XI/1037) prior to the commencement of the study. After providing information about the purpose of the study, details of procedures, risks and benefits to participants, written informed consent was obtained voluntarily from the participants regarding their enrolment and to undergo study-related procedures (i.e. upper gastrointestinal endoscopy). Confidentiality and anonymity of study participants were guaranteed during and after the study, both during data collection and data analysis by the researcher, by assigning coded numbers to each participant. Endoscopic procedures w