Hiatal Hernia

Published on 19/07/2015 by admin

Filed under Radiology

Last modified 19/07/2015

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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

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