Joint mobility in people with hiatus hernia

Z. S. Al-Rawi, K. Y. Al-Dubaikel1 and H. Al-Sikafi

Departments of Medicine and 1Surgery, College of Medicine, University of Baghdad and Baghdad Teaching Hospital, Baghdad, Iraq.

Correspondence to: Z. S. Al-Rawi, PO Box 28085, Al-Karkh, Baghdad, Iraq. E-mail: zsalrawi{at}uruklink.net


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objective. To assess joint mobility in people with hiatus hernia.

Methods. A comparative control study was made on 100 patients attending an endoscopic unit. Fifty patients with hiatus hernia were compared with a control group matched for age, sex and body mass index without hiatus hernia. Mobility was scored on a scale of 0–9.

Results. There were 11 (22%) patients in the hiatus hernia group with hypermobile joint score 4–9 compared with three (6%) subjects in the control group (P<0.001), whilst the total mobility score among hypermobile patients was 59 in the hiatus hernia group compared with 13 in the control group (P<0.005).

Conclusion. There is a positive correlation between the presence of hiatus hernia and joint mobility.

KEY WORDS: Hiatus hernia, Joint mobility.


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
From the earliest descriptions of joint laxity by Hippocrates (4th century BC) to the late 19th century, joint laxity remained unrecognized [1]. Thereafter, Sutro [2] described the association between joint laxity and rheumatological symptoms.

Hypermobility syndrome was defined by Kirk and Ansell [3] as joint laxity producing musculoskeletal complaints [3]. Joint hypermobility is recognized by movement of a joint beyond its normal range [4]. This is important in rheumatological practice because it produces a wide variety of articulator complaints, such as knee effusion [5], ligamentous injuries [1], dislocation [6], low back pain [7], spondylolisthesis [8] and osteoarthritis [4, 9].

Recent studies suggest that the clinical symptoms of hypermobility include not only locomotor disorders but also visceral ones. Grahame et al. [10] reported an increased incidence of mitral valve prolapse in people with hypermobility syndrome. Patients with joint laxity are more susceptible to visceral complications as a result of weakness of supporting structures. These include inguinal, femoral and umbilical hernia [1] and varicose veins [11, 12]. Association between hiatus hernia, diverticulum and loose joints has been reported [13]. Other visceral features that have been demonstrated in association with joint laxity are rectal [14] and uterine prolapse [15].

Hiatus hernia was first recognized as displacement of the stomach, and subsequently the term ‘partial thoracic sliding of the stomach’ was applied [16]. Hiatus hernia was regarded either as a sequel of congenital shortening of the oesophagus or as an acquired condition [17]. Hiatus hernia is relatively common, occurring in 5/1000 [16, 18] of the population. There are two main types: sliding hiatus hernia, which is the commonest type (85%) [17] and in which there is upward sliding of the gastro-oesophageal junction and stomach; in the paraoesophageal type (15%) the gastro-oesophageal junction remains below the diaphragm and the fundus with the greater curvature slides upwards [17, 19, 20]. The majority of patients with hiatus hernia are over the age of 40 yr, the incidence of the condition increases with age, and it is reported more in women than in men [18, 20, 21]. Hiatus hernia is associated with symptoms such as reflux oesophagitis, chest pain and dysphagia [20].

The aetiology of hiatus hernia is unknown but it may result from (i) muscular degeneration associated with ageing [19], (ii) increased intra-abdominal pressure, as in pregnancy, obesity, ovarian cysts and the wearing of tight corsets [19]; (iii) an increased amount of fatty tissue in the hiatus [19]; (iv) a lax phrenico-oesophageal ligament [22]; (v) congenital short oesophagus and other anatomical defects [22]; or (vi) oesophageal spasm and fibrosis [19].

Because ligamentous laxity and weakness of supporting structures may be aetiological factors for hiatus hernia, we decided to study its possible association with joint laxity.


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
A total of 100 patients were seen at the endoscope unit at Baghdad Teaching Hospital because of upper gastrointestinal complaints between April and December 1995. Fifty patients were diagnosed as having hiatus hernia and the remaining 50 patients, who were shown by endoscopy not to have hiatus hernia, were included as the control group.

Patients in both groups were assessed clinically for body height and weight, which were recorded with the patient in indoor clothing and without shoes. The body mass index (BMI) was calculated as BMI = weight (kg)/height (m)2.

Joint mobility was evaluated blindly by another observer using methods described by Carter and Wilkinson [5] and modified by Beighton et al. [23], producing a numerical score in the range 0–9. Patients scoring 0–3 were considered as normal and those scoring 4–9 were considered hypermobile.

Endoscopy was done for patients in both groups, and the diagnosis of hiatus hernia was confirmed by the finding of reflux gastric juice through the cardia, which will open on inspiration [17]. This is an all-or-nothing phenomenon. Furthermore, the levels of the following landmarks were reported for every oesophagoscopy: the location of the diaphragmatic hiatus in relation to the proximal stomach, the level of the squamocolumnar junction, and the proximal extent of the gastric mucosal folds in the hernia pouch. These are characteristics used for the precise diagnosis of hiatus hernia and reflux sequelae [24].

Because of a shortage of X-ray films, a barium meal examination was done for 32 patients, using the Trendelenburg position to demonstrate barium regurgitation [17]. The radiological diagnosis of hiatus hernia was made according to the criteria reported by Wolf [25].

Oesophageal manometric studies [24] and other specific investigations were not performed because of the unavailability of these tests.

A signed consent statement was taken from all individuals in both groups. Ethical approval was obtained from the ethics committee of the Republic of Iraq, Ministry of Health, Saddam Medical City.

The data were analysed statistically with the {chi}2 and t-tests.


    Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
The 50 patients in the hiatus hernia group comprised 28 males and 22 females (1.3:1) compared with 30 males and 20 females (1.5:1) in the control group.

The mean age was 48.7 yr for the hiatus hernia group and 47.3 yr for the control group (Table 1).


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TABLE 1. Age, sex and mean BMI in the hiatus hernia and control groups

 
The mean BMI was 23.9 for the hiatus hernia group and 23 for the control group.

The frequency distribution of mobility scores in the two groups is shown in Table 2 and Fig. 1. Twenty-two per cent of the patients in the hiatus hernia group scored 4–9 compared with 6% of the control group (P<0.001), whilst the total mobility score among the hypermobile patients was 59 in the hiatus hernia group compared with 13 in the control group (P<0.005).


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TABLE 2. Total mobility scores of the hiatus hernia and control groups

 


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FIG. 1. Frequency distribution of mobility score.

 
The number of individuals with hypermobile joints declined with age in both groups (P<0.01) (Table 3).


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TABLE 3. Mobility score and age in the hiatus hernia and control groups

 
When individuals in both groups were subdivided into young (20–39 yr) and old (40–69 yr) age groups, it was found that patients and controls showed significantly more joint mobility in the young than in the old age group.

The possible causes of increased intra-abdominal pressure were heavy work (reported in 15 and 18 individuals in the hiatus hernia and the control groups respectively) and being a housewife (19 and 18). The mean number of pregnancies was 3.5 and 3 in the patients with hiatus hernia and the control group respectively. One patient with hiatus hernia wore a corset.


    Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
The association between joint laxity and hiatus hernia has not been reported to date in a controlled study.

Hiatus has been observed in three reported cases out of 11 women with loose joints who were examined by barium meal for epigastric discomfort [11]. Hiatus hernia has also been reported in other individual patients with loose joints [13, 21, 26].

In the present study there were significantly more patients with joint mobility in the hiatus hernia group (22%) compared with the control group (6%) (P<0.001).

Also, the total mobility score was significantly higher in the hiatus hernia group (54) than in the control group (13) (P<0.005).

The finding of a significant decrease in joint hypermobility with age in the patient and control groups is in agreement with another report [27]. Although there are more patients with hypermobile joints in the old age (4) compared with none (0) in the controls, the differences were insignificant. We need to study more patients to see whether the finding of hiatus hernia is independent of the features of hypermobility as the patient ages.

This study was done during the year 1995, before the 1998 Brighton criteria [28] were issued. This is why we did not look beyond hypermobility to other features of the benign joint hypermobility syndrome.

The prevalence of joint hypermobility was low (6%) in our control group, compared with 12% of schoolchildren [29], 10% of healthy subjects [30] and 25.8% of male and 38% of female university students [31].

This could be explained by the fact that our control group included more men in middle age, whilst joint mobility decreases in prevalence with age and has female preponderance [3, 14, 32].

Recent surveys have shown a slightly increased incidence of hiatus hernia in women [19]. The present study, however, showed a sex ratio (M/F) in the hiatus hernia and control groups of 1.3:1 and 1.5:1 respectively. This was probably due to better tolerance and acceptance of endoscopy by men than women.

Predisposing factors, such as age, obesity, sex, parity and occupation, did not show a significant association with the hiatus hernia group.

This study agrees with other studies [19] showing that a high reported incidence of hiatus hernia is not related to age, sex and weight, and studies reporting a high incidence in younger age-groups [14].

It is concluded that there is a positive correlation between the presence of hiatus hernia and joint mobility.


    Acknowledgments
 
Grateful thanks are due to Professor Howard Bird, University of Leeds, for reviewing the manuscript, to Dr H. J. Al-Rawi, Histopathology Department, St Thomas’s Hospital, for much help, and to Moa’ath Al-Rawi for typing the manuscript.


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

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Submitted 1 July 2002; revised version accepted 24 March 2003.



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