Saint’s Triad

Aetiology

There is no common causal mechanism linking the three conditions. Their coexistence is considered a result of:

• Shared demographic risk factors: increased age, female sex, Western diet, and low dietary fibre
• A tendency toward degenerative or motility-related changes in the gastrointestinal tract
• Possible connective tissue or smooth muscle vulnerability

Saint himself cautioned against pathophysiological assumptions, noting the “associated, not causally linked“ nature of the triad.

Clinical Features

Patients may present with:

• Symptoms of gallbladder disease (e.g., right upper quadrant pain, nausea)
• Reflux or dysphagia from hiatal hernia
• Abdominal pain or altered bowel habits from diverticulosis (especially if complicated)

However, Saint’s Triad is often discovered incidentally during imaging or surgery.

Diagnosis

Diagnosis relies on identifying all three components:

1. Hiatal hernia: via barium swallow, endoscopy, or imaging
2. Gallstones: via ultrasound or CT
3. Colonic diverticulosis: often found on CT, colonoscopy, or contrast enema

No special diagnostic protocol exists; recognition is retrospective in most cases.

Incidence

• More common in Western populations; rare in Asian cohorts
• Reported in 1.02% of patients undergoing upper GI fluoroscopy in a 1987 study
• In another series of 5,000 barium meal exams, the triad appeared in 0.26%

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Occam’s Razor vs Hickam’s Dictum

The Saint’s Triad Dictum

Saint’s Triad has become a clinical metaphor supporting Hickam’s Dictum, the assertion that “a patient can have as many diseases as they damn well please.” It directly challenges Occam’s Razor, the principle of diagnostic parsimony, which urges clinicians to find a single unifying cause for multiple symptoms “when investigating a patient with multiple symptoms, a single unifying diagnosis should be sought“.

Saint cautioned that forcing a unifying diagnosis may lead to dangerous oversights, and that coexisting unrelated pathologies are not uncommon, especially in elderly or polymorbid patients.

Surgical Significance

Surgeons and radiologists encountering one component are advised to actively search for the others, especially in older patients with vague abdominal symptoms. Awareness prevents diagnostic anchoring and underdiagnosis of comorbid conditions.

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History of Saint’s Triad

1946 – Charles F. M. Saint (1886–1973), Professor of Surgery at the University of Cape Town (1920–1946), anecdotally highlighted the importance of suspecting multiple coexisting diseases when clinical signs diverged from classic presentations. His dictum anticipated the triad later bearing his name.

…the importance of considering the possibility of multiple separate diseases in a patient whenever his or her history and the results of the physical examination were atypical of any single condition.

1948 – Radiologist C.J.B. Muller at Johannesburg General Hospital published the first clinical report of Hiatus hernia, diverticula and gall stones* : Saint’s triad in three patients.

During last year Professor Saint of Cape Town mentioned to me during a discussion about pathology, the association of hiatus hernia, sacculi of the colon and gall-stones…If looked for, as many cases of the present triad will certainly be found. Its recognition I really of importance to the patient. I think it may well be referred to as “Saint’s Triad“.

Muller 1947

1951 – Eddy Davis Palmer (1917-2010) reviewed 31 patients with cholelithiasis and found 5 with the full triad. He noted the diagnostic danger of prematurely attributing symptoms to a single pathology when others may be involved.

One would be hard put to justify an assumption that there may be some basic causal significance in the association of these common diseases…it would behoove the physician to be rather skeptical of accepting one demonstrated entity as the explanation for the patient’s symptoms.

Palmer 1951

1955 – Palmer then studied 170 adults with hiatus hernia, finding Saint’s triad in 14% (24 patients). He emphasized that gallbladder disease was most commonly presumed responsible but had the poorest outcomes post-cholecystectomy, indicating the true clinical burden often lay elsewhere.

The symptomatic results of cholecystectomy were notably poor… it was evident that more than one lesion was often responsible for the symptoms

Palmer, 1955

1976 – Denis P. Burkitt &and Andrew R. Walker proposed a unifying mechanism: fibre-deficient diets leading to visceral strain. They drew epidemiological parallels between the three conditions, associating their rising incidence with Western dietary patterns.

It thus seems likely that not only diverticular disease and hiatus hernia, but also gallstones, are causally related to fibre-depleted diets, and that the relationship suggested may adequately explain the clinical associations originally recognised by Saint.

Burkitt DP, Walker AR 1976

1987 – In a radiological study of 684 patients, Scaggion identified 7 complete triads (1.02%) and 86 bifocal associations. He concluded that the triad’s observed frequency was four times higher than expected by chance alone, statistically supporting its clinical validity.

2008 – Hauer-Jensen et al. propose “Herniosis” as a unifying aetiology. They argue that rather than being a coincidental co-occurrence of three common conditions (hiatal hernia, colonic diverticulosis, and cholelithiasis), Saint’s Triad may be the result of an underlying systemic disorder of connective tissue, termed herniosis. This marked a paradigm shift, aligning the triad more closely with Ockham’s razor rather than Hickam’s dictum.

2015 – Simic et al. reinforce “herniosis” as a biological explanation. They reviewed Saint’s triad through the lens of diagnostic philosophy and modern molecular insights. They noted that patients with Saint’s Triad often exhibit altered collagen metabolism, with changes in collagen type I/III ratios, and associated ultrastructural abnormalities in the phrenoesophageal ligament and bowel wall.

The study connected diverticulosis, hiatal hernia, and gallstones to systemic connective tissue disorders and postulated a genetic component involving COL3A1 mutations. This supports the concept that these conditions are not coincidental but reflect a shared pathophysiological substrate.

Current understanding – Saint’s Triad as a connective tissue disorder:
Today, Saint’s Triad is no longer simply an odd cluster of symptoms or a cautionary tale against diagnostic simplicity. Rather, it is increasingly considered a phenotypic expression of systemic herniosis, possibly inherited or acquired. This shift enhances its diagnostic relevance and has implications for surgical outcomes, especially in hernia repairs and reflux disease interventions.

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Associated Person

• William of Occam (1287-1347)
• John Bamber Hickam (1914-1970)
• Charles Frederick Morris Saint (1886-1973)
• Eddy Davis Palmer, (1917-2010)

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References

Original Articles

• Muller CJB. Hiatus hernia, diverticula and gall stones* : Saint’s triad. South African Medical Journal 1948; 22(11): 376-382
• Palmer ED. Saint’s triad: hiatus hernia, diverticulosis coli and gall stones. Am J Dig Dis. 1951 Aug;18(8):240-1.
• Palmer ED. Saint’s triad (hiatus hernia, gall stones and diverticulosis coli): the problem of properly directing surgical therapy. Am J Dig Dis. 1955 Nov;22(11):314-5.
• Saint CF. Saint’s triad. The origin and story of its recognition. Rev Surg. 1966 Jan-Feb;23(1):1-4.
• Burkitt DP, Walker AR. Saint’s triad: confirmation and explanation. S Afr Med J. 1976 Dec 18;50(54):2136-8. 

Review Articles

• Scaggion G, Poletti G, Riggio S. Saint’s triad. Statistico-epidemiologic research and case contribution. Minerva Med. 1987
• Hilliard AA, Weinberger SE, Tierney LM, Midthun DE, Saint S. Occam’s Razor versus Saint’s Triad. N Engl J Med 2004; 350: 599-603
• Hauer-Jensen M, Bursac Z, Read RC. Is herniosis the single etiology of Saint’s triad? Hernia. 2009 Feb;13(1):29-34.
• Dos Santos VM, Dos Santos LA. Comments on Saint’s triad. Surg Case Rep. 2015 Dec;1(1):115. doi: 10.1186/s40792-015-0116-3. Epub 2015 Nov 14.
• Cadogan M. Eponymous Triads. LITFL