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Hiatal Hernia

Published on 19/07/2015 by admin

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Last modified 22/04/2025

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 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
image Herniated contents lie alongside esophagus

Imaging Recommendations

• Best imaging tool

image Barium esophagram and upper GI studies
• Protocol advice

image Fluoroscopic-guided single-contrast barium studies (patient prone right anterior oblique)

– Obtain fully distended views in several positions, including upright
– Film with full inspiration and Valsalva
image Sensitivity: Full-column technique (100%), mucosal relief (52%), double-contrast techniques (34%)

DIFFERENTIAL DIAGNOSIS

Phrenic Ampulla

• Saccular, slightly more distensible distal segment of esophagus that communicates with stomach
• Phrenic ampulla or vestibule corresponds to location of lower esophageal sphincter (LES)

image 2-4 cm long high-pressure zone extends up from GE junction into thorax
image At upper end of sphincter; muscle coalescence called A ring, B ring at lower end of ampulla at GE junction
image Ampulla has bulbous configuration when fully distended

Postoperative Change

• Esophagectomy with gastric pull-up procedure

image Gastric conduit is pulled into chest to replace resected esophagus

Pulsion Diverticulum

• Usually large sac-like protrusion in epiphrenic region; tends to remain filled after most barium is emptied
• From lateral esophageal wall of distal 10 cm
• Lack of gastric folds within diverticulum helps distinguish from hernia

PATHOLOGY

General Features

• Etiology

image Acquired complex multifactorial etiology

– Becoming more common with obesity, aging, lack of conditioning
– Multiparous women have increased incidence
– Reflux itself induces irritation that causes spasm of longitudinal muscles of esophagus

image Shortens esophagus, which pulls stomach up into chest
• Associated abnormalities

image Diverticulosis (25%), reflux esophagitis (25%), duodenal ulcer (20%), or gallstones (18%)

Staging, Grading, & Classification

• Surgical classification of hiatal hernia

image Type I: GE junction and gastric cardia are intrathoracic (sliding hiatal hernia)
image Type II: GE junction intraabdominal gastric fundus intrathoracic (paraesophageal hernia)
image Type III: Both GE junction and fundus are in chest (paraesophageal hernia)
image Type IV: GE junction and all of stomach in chest (paraesophageal hernia)

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Sliding HH

– Symptoms of GE reflux disease (GERD)
– Substernal or epigastric burning pain, regurgitation, dysphagia, hoarse voice
image Paraesophageal hernia (PEH)

– May be asymptomatic; incidental finding on imaging
– Anemia, abdominal or chest pain, vomiting

image Especially if strangulation or volvulus occur
– Common in elderly with multiple other medical problems
– GERD and reflux esophagitis are uncommon in PEH (according to some authors)
– Others believe reflux is common, and danger of volvulus makes repair necessary
• May be incidentally noted on upper GI series or CT
• Found during endoscopy

image Cameron ulcers and erosions within herniated stomach

– In 5.2% of patients with HH
– Acute upper GI bleeding (6.3%)
– Persistent, recurrent iron deficiency anemia (8.3%)
– Pathogenesis: Mechanical trauma, ischemia, acid mucosal injury

Demographics

• Age

image Prevalence increases with age
• Gender

image M < F
• Epidemiology

image > 90% of all HH are sliding (type I)
image < 10% are paraesophageal 

– Seem to be increasing in prevalence
– May be due to ↑ age and obesity in population

Natural History & Prognosis

• Sliding (type I) HH

image Morbidity is due to associated GERD
image ↑ incidence of Barrett esophagus, and ↑ incidence of carcinoma
• Complications of PEH

image PEHs may enlarge
image Types III and IV at risk for volvulus, strangulation, ischemia, perforation
image Complications of nonsurgical treatment may be sudden and severe

Treatment

• Sliding HH

image Medical treatment and lifestyle modification; treatment same as for GERD
image Increasing use of laparoscopic fundoplication to treat GERD and to repair HH
• PEH

image Surgery is warranted unless patient is prohibitive operative risk

– Hernial sac excision, crural closure, and antireflux procedure (fundoplication or gastropexy)
– Increasing use of laparoscopic repair has decreased morbidity of procedure

DIAGNOSTIC CHECKLIST

Consider

• Esophagram and upper GI series remain best test to demonstrate and classify HHs
• CT (and MR) are complementary to barium studies

image
(Left) The GE junction image in this patient with a type III PEH is in the chest, along with a substantial portion of the stomach. The stomach is pinched as it traverses the diaphragmatic hiatus image. Type III PEHs are encountered with increased frequency.
image
(Right) Upper GI in a patient with type IV PEH is shown. Intrathoracic stomach shows that while an air-fluid level is present within the stomach, there is no evidence of twisting or obstruction of the stomach; however, this patient is at risk for volvulus and strangulation.
image
(Left) Chest film in an elderly man with chest pain shows a widened mediastinum with an air-fluid level to the right of the spine image and what appear to be bowel segments image to the left of the thoracic spine.

image
(Right) Axial CT in the same patient shows that most of the stomach image lies within the right hemithorax and the colon image lies to the left and behind the heart, along with omental fat, all herniating through a wide defect in the esophageal hiatus.
image
(Left) A barium enema in the same patient confirms that the splenic flexure of the colon is herniated, and there is a “waist” image or compression of the colon as it traverses the hiatus.

image
(Right) Post evacuation film from the barium enema shows barium retained within the herniated colon image. Note the position of a nasogastric tube image within the herniated stomach and duodenum, which is within the abdomen.
image
Fluoroscopic upper GI series shows a type III paraesophageal hernia with a large fungation mass within the herniated stomach in this patient with adenocarcinoma.

image
Axial CECT shows herniation of the stomach and colon through a grossly enlarged esophageal hiatus.
image
Axial CECT shows a large type III paraesophageal hernia.
image
Upright film from barium esophagram shows a nonreducible, type III paraesophageal hernia with fundus and gastroesophageal junction above the diaphragm.
image
Type II paraesophageal hernia is shown The gastric fundus has herniated into the chest, but the gastroesophageal junction image remains below the diaphragm.
image
Esophagram shows a small sliding HH. Note the thickened gastric folds image in the hernia continuing into the abdomen. The “feline” appearance of the esophageal mucosa is due to reflux.

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