Sliding (axial) hiatal hernia (HH): Gastroesophageal (GE) junction and gastric cardia pass through esophageal hiatus
Paraesophageal (rolling) hernia: Gastric fundus ± other parts of stomach herniate into chest
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Surgical classification
Type I: Sliding HH (only cardia in chest); most common type
Type II Paraesophageal (PEH): GE junction in normal position under diaphragm, fundus in chest (very rare)
Type III PEH: GE junction in chest, along with fundus ± other portions of stomach (2nd most common HH)
Type IV PEH: Intrathoracic stomach ± volvulus
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Type I (sliding HH): Signs on upper GI series
Lower esophageal mucosal (B) ring observed ≥ 2 cm above diaphragmatic hiatus
Often reducible in erect position
Numerous (> 6) longitudinal gastric folds within HH continue through hiatus into abdominal part of stomach
Gastric folds converging superiorly toward a point several centimeters above diaphragm
TOP DIFFERENTIAL DIAGNOSES
CLINICAL ISSUES
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Medical treatment and lifestyle modification (treatment same as for gastroesophageal reflux disease [GERD])
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Increasing use of laparoscopic fundoplication to treat GERD and to repair all types of HH
TERMINOLOGY
Abbreviations
Definitions
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Protrusion of part of stomach through esophageal hiatus of diaphragm
IMAGING
General Features
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Best diagnostic clue
Fluoroscopy after barium meal showing some portion of stomach in thorax
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2 general types
Sliding (axial)
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Gastroesophageal (GE) junction and gastric cardia pass through esophageal hiatus of diaphragm into thorax
Paraesophageal (rolling) hernia
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Gastric fundus ± other parts of stomach herniate into chest
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Surgical classification
Type I: Sliding HH (only cardia in chest)
Type II paraesophageal (PEH): GE junction in normal position (under diaphragm)
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Fundus herniates alongside esophagus (very rare)
Type III PEH: GE junction in chest, along with fundus ± other portions of stomach
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2nd most common type (after type I)
Type IV PEH: Intrathoracic stomach ± volvulus
Radiographic Findings
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Fluoroscopic-guided barium esophagram and upper GI
Type I (sliding HH)
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Lower esophageal mucosal (B) ring observed ≥ 2 cm above diaphragmatic hiatus
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Prominent diagonal notch may be seen on left lateral and superior aspect of HH
Due to crossing gastric sling fibers at cardiac incisura
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± kink or narrowing of HH at esophageal hiatus; extrinsic compression by diaphragm
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Esophageal peristaltic wave stops at GE junction
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Tortuous esophagus that has eccentric junction with hernia
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Often reducible in erect position
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Numerous (> 6) longitudinal gastric folds within HH continue through hiatus into abdominal part of stomach
Gastric folds converging superiorly toward point several centimeters above diaphragm
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Areae gastricae pattern demonstrated within herniated portion of fundus
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“Riding ulcers” at hiatal orifice
Repeated trauma of gastric mucosa on ridge riding over hiatus
Paraesophageal hernia (types II to IV)
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Portion of stomach anterior or lateral to esophagus in chest
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Frequently nonreducible
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± gastric ulcer of lesser curvature at level of diaphragmatic hiatus
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Type III and IV: Prone to volvulus
CT Findings
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Widening of esophageal hiatus
Dehiscence of diaphragmatic crura (> 15 mm); increased distance between crura and esophageal wall
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Focal fat collection in middle compartment of lower mediastinum
Omentum herniates through phrenicoesophageal ligament
May see ↑ in fat surrounding distal esophagus