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Objective: Sliding type-I hiatal hernia (HH) is commonly diagnosed using upper endoscopy, barium swallow (BS) or esophageal manometry (EM). Current data suggests that endoscopy is superior to EM or BS. Recently, high resolution manometry (HRM) has become available for the assessment of esophageal motility. The unique ability of this technique to display spatial and topographic pressure profiles of gastroesophageal junction (GEJ) and crural diaphragm (CD) in real time suggests that it may be a better means for the assessment of an overt type-1 HH. The objective of the current study was to compare HRM with endoscopy for diagnosis of sliding HH. Methods: Data was analyzed retrospectively for 83 consecutive patients (61% females, mean age 52 ±13.2Yrs.) with objective gastroesophageal reflux disease (GERD) who were considered for laparoscopic antireflux surgery between 2006 and 2008 and had preoperative HRM and endoscopy. HH was defined as GEJ ≥2.5 Cm. above the CD. Intraoperative diagnosis of HH was used as the gold standard. Sensitivity, specificity and likelihood ratios of a positive test and a negative test were used to compare the performance of the two diagnostic modalities. Results: Forty two patients were found to have a type-I HH during surgery. Twenty four patients had manometric criteria for a HH by HRM and 36 patients were described as having a HH by endoscopy. False positive results were significantly fewer (p=0.003) with HRM (2/41) as compared to endoscopy (13/41). There were no significant differences in the false negative results between the two modalities (22/42 Vs 13/36, p=0.36). Sensitivity, specificity and likelihood ratios for HRM and endoscopy are shown in table-1. Conclusions: HRM has better specificity and ability to rule-in an overt type-I HH (greater likelihood ratio of a positive test). However, relatively higher false negative results with HRM as compared to endoscopy (47.68% Vs 36.12%) counteract its clear superiority over endoscopy. Both HRM and endoscopy are unreliable for ruling-out type-I HHs. Negative result for a HH by either modality mandates additional testing.
Table-1. Sensitivity, specificity and likelihood ratios for HRM and endoscopy

	High Resolution Manometry (HRM)	Endoscopy
Sensitivity	52.38%	63.88%
Specificity	95.12%	68.29%
Likelihood ratio of a positive test	10.72	2.01
Likelihood ratio of a negative test	0.50	0.52