Hiatal hernias in patients with GERD-like symptoms: evaluation of dynamic real-time MRI vs endoscopy

  • Ali Seif Amir HosseiniEmail author
  • Johannes Uhlig
  • Ulrike Streit
  • Annemarie Uhlig
  • Thilo Sprenger
  • Edris Wedi
  • Volker Ellenrieder
  • Michael Ghadimi
  • Martin Uecker
  • Dirk Voit
  • Jens Frahm
  • Joachim Lotz
  • Lorenz Biggemann
Magnetic Resonance



To assess the diagnostic potential of real-time MRI for assessment of hiatal hernias in patients with GERD-like symptoms compared to endoscopy.

Material and methods

One hundred eight patients with GERD-like symptoms were included in this observational cohort study between 2015 and 2017. Real-time MRI was performed at 3.0 Tesla with temporal resolution of 40 ms, dynamically visualizing the esophageal transport of a pineapple juice bolus, its passage through the gastroesophageal junction, and functional responses during Valsalva maneuver. Hernia detection on MRI and endoscopy was calculated using contingency tables with diagnosis of hernia on either modality as reference.


Of 108 patients, 107 underwent successful MRI without adverse events; 1 examination was aborted to inability to swallow pineapple juice in supine position. No perforation or acute bleeding occurred during endoscopy. Median examination time was 15 min. Eighty-five patients (79.4%) were diagnosed with hiatal hernia on either real-time MRI or endoscopy. Forty-six hernias were visible on both modalities. Seventeen hernias were evident exclusively on MRI, and 22 exclusively on endoscopy. Sixteen of the 63 MRI-detected hernias (25.4%) were detectable only during Valsalva maneuver, which were smaller compared to hernias at rest (median − 13.5 vs − 33.0 mm, p < 0.001). Diagnostic accuracy for hernia detection was comparable for MRI and endoscopy (sensitivity 74% vs 80%, p = 0.4223; specificity 100% vs 100%, p > 0.99).


Real-time MRI is a fast and safe modality for assessment of the gastroesophageal junction, without radiation exposure or administration of gadolinium-based contrast media. Although MRI and endoscopy yield comparable diagnostic accuracy, dynamic MRI sequences are able to visualize hiatal hernias that were occult on static MRI sequences or endoscopy in a relevant number of cases.

Key Points

• Real-time MRI is a safe and fast imaging modality for examination of the gastroesophageal junction, combining anatomical and functional information for enhanced detection of hiatal hernias.

• Real-time MRI and endoscopy yield comparably high diagnostic accuracy: real-time MRI visualizes hiatal hernias that were occult on endoscopy in a relevant number of patients; however, several hiatal hernias detected on endoscopy were occult on real-time MRI.

• There is clinical potential of real-time MR imaging in patients with GERD-like symptoms and equivocal findings on endoscopy or pH-metry, for anatomical visualization in patients planned for surgical intervention, or those with suspected fundoplication failures.


Hiatal hernia Gastroesophageal reflux disease Magnetic resonance imaging Endoscopy EDG 





Gastroesophageal reflux disease


Lower esophageal sphincter


Proton pump inhibitor



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Ali Seif Amir Hosseini.

Conflict of interest

Jens Frahm and Martin Uecker are co-inventors of a patent covering the real-time MRI technique used in this study.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• descriptive diagnostic study

• performed at one institution

Supplementary material

Video 1

Real-time MRI (40 ms resolution) of the lower esophageal sphincter (LES) during bolus passage (pineapple juice). Case 1 shows a subject with hiatal hernia on real-time MRI while occult on endoscopy. Video reveals regular bolus arrival in the distal esophagus and bolus transit through LES. Subsequently regular clearance of the distal esophagus. After performing Valsalva hiatal herniation can be observed on coronal oblique and sagittal planes. (MP4 32,267 kb)

Video 2

Real-time MRI (40 ms resolution) of the LES during bolus passage (pineapple juice). Case 2 shows a subject with hiatal hernia on endoscopy while occult on real-time MRI. Video reveals regular bolus arrival in the distal esophagus and bolus transit through LES. During Valsalva maneuver no morphological criteria for a hernia (cephalad migration of the gastric fundus) can be observed. (MP4 23,980 kb)

Video 3

Real-time MRI (40 ms resolution) of the gastroesophageal junction during bolus passage (pineapple juice), showing passage in coronal and sagittal planes. Case 3 shows a subject with hiatal hernia on both modalities, real-time MRI and endoscopy. Video reveals regular esophageal bolus transit and normal propulsive peristalsis of the distal esophagus. During Valsalva hiatal herniation of the gastric fundus can be observed on sagittal oblique planes. (MP4 41,826 kb)


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  • Ali Seif Amir Hosseini
    • 1
    Email author
  • Johannes Uhlig
    • 1
  • Ulrike Streit
    • 1
  • Annemarie Uhlig
    • 2
  • Thilo Sprenger
    • 3
  • Edris Wedi
    • 4
  • Volker Ellenrieder
    • 4
  • Michael Ghadimi
    • 3
  • Martin Uecker
    • 1
    • 5
  • Dirk Voit
    • 6
  • Jens Frahm
    • 5
    • 6
  • Joachim Lotz
    • 1
    • 5
  • Lorenz Biggemann
    • 1
  1. 1.Department of Diagnostic and Interventional RadiologyUniversity Medical Center GöttingenGöttingenGermany
  2. 2.Department of UrologyUniversity Medical Center GöttingenGöttingenGermany
  3. 3.Department of General, Visceral, and Paediatric SurgeryUniversity Medical CenterGöttingenGermany
  4. 4.Department of Gastroenterology and Gastrointestinal OncologyUniversity Medical Center GöttingenGöttingenGermany
  5. 5.DZHK (German Centre for Cardiovascular Research)GöttingenGermany
  6. 6.Biomedical NMR, Max-Planck-Institute for Biophysical ChemistryGöttingenGermany

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