Hiatal Hernia

 Sliding (axial) hiatal hernia (HH): Gastroesophageal (GE) junction and gastric cardia pass through esophageal hiatus


image Paraesophageal (rolling) hernia: Gastric fundus ± other parts of stomach herniate into chest


• Surgical classification
image Type I: Sliding HH (only cardia in chest); most common type

image Type II Paraesophageal (PEH): GE junction in normal position under diaphragm, fundus in chest (very rare)

image Type III PEH: GE junction in chest, along with fundus ± other portions of stomach (2nd most common HH)

image Type IV PEH: Intrathoracic stomach ± volvulus

• Type I (sliding HH): Signs on upper GI series
image Lower esophageal mucosal (B) ring observed ≥ 2 cm above diaphragmatic hiatus

image Often reducible in erect position

image Numerous (> 6) longitudinal gastric folds within HH continue through hiatus into abdominal part of stomach

image Gastric folds converging superiorly toward a point several centimeters above diaphragm




TOP DIFFERENTIAL DIAGNOSES




• Phrenic ampulla

• Postoperative change

• Pulsion diverticulum


CLINICAL ISSUES




• Medical treatment and lifestyle modification (treatment same as for gastroesophageal reflux disease [GERD])

• Increasing use of laparoscopic fundoplication to treat GERD and to repair all types of HH

image
(Left) Graphic outlines the surgical classification of hiatal hernias (HH). Type I is a sliding HH, and types II-IV are paraesophageal hernias. Type III is the 2nd most common type, but it is rare compared to type I (sliding HH).


image
(Right) Esophagram in a patient with type I sliding HH shows the lower esophageal sphincter, or phrenic ampulla, marked by the A ring image proximally and the B ring image distally. Just below the B ring is the herniated portion of the gastric cardia image.

image
(Left) Film from a barium esophagram in a patient with type I sliding HH shows the gastroesophageal (GE) junction, marked by the B ring image. Gastric folds image extend up through the hiatus.


image
(Right) Esophagram in the same patient (supine position) reveals reflux image. While reflux is commonly seen in patients with sliding HHs, it is uncertain whether the HH causes the reflux or vice versa.


TERMINOLOGY


Abbreviations




• Hiatal hernia (HH)


Definitions




• Protrusion of part of stomach through esophageal hiatus of diaphragm


IMAGING


General Features




• Best diagnostic clue
image Fluoroscopy after barium meal showing some portion of stomach in thorax

• 2 general types
image Sliding (axial) 
– Gastroesophageal (GE) junction and gastric cardia pass through esophageal hiatus of diaphragm into thorax

image Paraesophageal (rolling) hernia
– Gastric fundus ± other parts of stomach herniate into chest

• Surgical classification
image Type I: Sliding HH (only cardia in chest)

image Type II paraesophageal (PEH): GE junction in normal position (under diaphragm)
– Fundus herniates alongside esophagus (very rare)

image Type III PEH: GE junction in chest, along with fundus ± other portions of stomach
– 2nd most common type (after type I)

image Type IV PEH: Intrathoracic stomach ± volvulus


Radiographic Findings




• Fluoroscopic-guided barium esophagram and upper GI
image Type I (sliding HH)
– Lower esophageal mucosal (B) ring observed ≥ 2 cm above diaphragmatic hiatus

– Prominent diagonal notch may be seen on left lateral and superior aspect of HH
image Due to crossing gastric sling fibers at cardiac incisura

– ± kink or narrowing of HH at esophageal hiatus; extrinsic compression by diaphragm

– Esophageal peristaltic wave stops at GE junction

– Tortuous esophagus that has eccentric junction with hernia

– Often reducible in erect position

– Numerous (> 6) longitudinal gastric folds within HH continue through hiatus into abdominal part of stomach
image Gastric folds converging superiorly toward point several centimeters above diaphragm

– Areae gastricae pattern demonstrated within herniated portion of fundus

– “Riding ulcers” at hiatal orifice
image Repeated trauma of gastric mucosa on ridge riding over hiatus

image Paraesophageal hernia (types II to IV)
– Portion of stomach anterior or lateral to esophagus in chest

– Frequently nonreducible

– ± gastric ulcer of lesser curvature at level of diaphragmatic hiatus

– Type III and IV: Prone to volvulus


CT Findings




• Widening of esophageal hiatus
image Dehiscence of diaphragmatic crura (> 15 mm); increased distance between crura and esophageal wall

• Focal fat collection in middle compartment of lower mediastinum
image Omentum herniates through phrenicoesophageal ligament

image May see ↑ in fat surrounding distal esophagus

• CT clearly demonstrates paraesophageal hernia through widened esophageal hiatus
image Visualize size, contents, orientation of herniated stomach within lower thoracic cavity

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Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Hiatal Hernia

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