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QuickTime and a decompressor are needed to see this picture.

QuickTime and a decompressor are needed to see this picture.

HiatalHerniawithComplications ofGastricVolvulus
Josu Zapata,HMSIII GillianLieberman,MD January25,2010 RadiologyCoreClerkship,BIDMC

Agenda
PatientReport:DB Differentialdiagnosis AnatomyReview Whatisahiatalhernia? Importanceofproperdiagnosis Menuoftests Radiologicexamples ReturntodiagnoseDB Resolutionofcase Review

PatientReport
HPI: DBisan89yearoldwomancomplaining ofseveraldaysofnausea,vomiting,and retrosternalheaviness followingmeals Hasbeenunabletotolerateliquidsorsolids sincesymptomsbegan Nowexperiencingsomeepisodesofacute pain

PatientReport
PMH: knownhiatalhernia,HTN,A.fib,CAD,DM PSH: Aorticvalvereplacement,ORIFRhip Meds: Noncontributory Vitals: T:100.0HR:89BP:124/67RR:2002sat:95%
onRA tenderness/guarding,+BS

FocusedPhysicalExam: Norebound

ExhaustiveDifferentialDiagnosis
MyocardialInfarction AorticDissection PulmonaryEmbolism GERD Achalasia Diffuseesophagealspasm Scleroderma ChagasDisease Esophagealmass(neoplasm,foreignbody,bezoar,Schatzkis) Esophagealstrictureorwebs Diverticula(Zenkers,KillianJameson) HiatalHernia

NarrowedDifferentialDiagnosis
HiatalHernia Achalasia Diffuseesophagealspasm Esophagealmass Esophagealstrictureorwebs Diverticula(Zenkers,KillianJameson)

Forourteachingpurposeswewill onlybediscussingwhatourpatient wasultimatelyfoundtohave

DBsFinalDiagnosis
HiatalHernia Achalasia Diffuseesophagealspasm Esophagealmass Esophagealstrictureorwebs Diverticula(Zenkers,KillianJameson)

Hiatal Hernia

AnatomyReview&BaSw:TheEsophagus
-24 cm muscular tube from pharynx to stomach -Described as featureless -A Ring: muscular ring at tubulovestibular junction -B Ring: Marker of GEJ
BaSw Fluoroscopy Slide courtesy of Jay Pahade, MD

AnatomyReview:TheDiaphragm
-Muscle layer that separates chest from abdomen -3 openings for the esophagus, aorta, & IVC
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-Esophageal hiatus is not perfectly tight so contents can pass through

Kahrilas,P. et Al. Best Pract Res Clin Gastroenterol. 2008; 22(4): 601-616.

AnatomyReview:TheStomach

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http://www.histopathology-india.net/stomach.jpg

AnatomyReview:Normal
GEJ is held within the abdomen by diaphragmatic crus

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http://www.nlm.nih.gov/medlineplus/ency/presentations/100028_1.htm

HiatalHernia:TheBasics
Definition: Herniationofabdominalcontentsthrough theesophagealhiatusofthediaphragm Thoughttobeduetomuscleweakeningandlossof elasticity,particularlyofphrenicoesophagealligament Incidenceincreasewithage,60%ofpopulationoverage 60affected Fourtypescategorizedbyanatomicalrelationshipsof criticalstructures
GEJ,Stomach,DiaphragmaticHiatus,OtherViscera

HiatalHernias:TypeI
SlidingHiatalHernia(95%)
GEJ2cmormoreabovethe diaphragmatichiatus Clinicallysilentorpresents withGERD PlacestheLESinthethorax, thuseliminatingthe bolsteringaffectofthecrura andexposingtheLESto negativeintrathoracic pressure Dynamicactionofswallowing addstodifficultyofdiagnosis

Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414

HiatalHernias:TypeII
Paraesophagealor RollingHiatalHernia
GEJremainsfixedin properlocation Partofstomach herniatesintothechest Clinicallyasymptomatic orpresentswith symptomsofsubsternal pain,postprandial fullness, nausea/vomiting,and SOB
Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414

HiatalHernias:TypeIII
MixedHiatalHernia
bothGEJandpartofthe stomachherniatesinto thechest Clinicallyasymptomatic orpresentswith symptomsofsubsternal pain,postprandial fullness, nausea/vomiting,and SOB

Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414

HiatalHernias:TypeIV
NonStomachViscera Herniates
Somedebateabout name,somebelievethis isavariationofatype2 or3 Clinicallyasymptomatic orpresentswith symptomsofsubsternal pain,postprandial fullness, nausea/vomiting,and SOB
Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414

HiatalHernias:Management
TypeI iseitherasymptomaticor associatedwithGERDandifso,typically respondstomedical managementandis onlysurgicalinrarecases TypesIIIV tendtoexpandovertimeand havetheabilitytorotateandaretherefore typicallyreducedsurgically

TypeIIIVHiatalHernias:Major Complications
VisceralRotation:
ThiscancauseGastricVolvulusand subsequentstrangulationofthestomach (33%)
Surgicalemergencyduetopotentialfor ischemia BorchardtsTriad: Pain,Retchingwithout vomiting,InabilitytopassNGtube(foundin 70%ofptswithstrangulation)

DiagramsofGastricVolvulus
Mesenteroaxial Rotation
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Organoaxial Rotation - Most Common


Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414

MenuofTestsforImagingHiatalHernias

BaSw:testofchoice(seenextslide) CT: occasionallyobtainedtobettercharacterizethe herniainunclearcasesorbeforesurgery PlainFilm: diagnosiscanbesuggestedbyanairfluid levelinretrocardiacareaonCXRorKUB


Oftenanincidentalfindinggiventhehighprevalenceof hiatalhernia

Endoscopy Manometry

ImagingModalities:BariumSwallow
BariumSwallow: thestudy ofchoiceforinitial evaluation Oftenallthatisneeded fordiagnosis Doubleorsinglecontrast (BaSO4 NaHCO3) Dynamicstudydone withfluoroscopy Importantbecause GEJmoveswith swallowing

QuickTime and a decompressor are needed to see this picture.

http://theodoregray.com/PeriodicTable/Elements/056/index.s7.html#sample3

Howtoevaluatetheimaging
HiatalHerniadiagnosisisbasedonanatomy:
NeedtoidentifytheGEJ,thestomach,andtheir relationshiptothediaphragmatichiatus Usecluessuchasthecontourofesophaguswhich shouldbefeatureless vs.rugaeinstomach TypeI:2cmrule atleast2cmbetweenEGJand diaphragmatichiatustodifferentiatefrom physiologicherniation TypeIIIV: GastricVolvulus lookfortheNGtube, distention,obstructionofflow,andinversionof curvaturesorothersignsofrotation

TypeI:SlidingHiatalHerniaonBaSw
BaSw fluoroscopy

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Gastric Rugae

Diaphragm

Kahrilas P. et Al Approaches to the Diagnosis and Grading of Hiatal Hernia. Best Pract Res Clin Gastroenterol. 2008 22(4):601-616

TypeII:ParaesophagealHiatal HerniaonCT
NG Tube Illustrating the path of the esophagus and that the GEJ is below the diaphragm
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Gastric Antrum is protruding into the thorax

CT Sagittal Abbara S. et Al Intrathoracic Stomach Revisited. AJR 2003 181:403-414

TypeIII:MixedHiatalHerniaonBaSw
GEJ is displaced above the diaphragm

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A large part of the stomach has herniated as well

BaSw fluoroscopy Image Courtesy of Yiming Gao, MD

Rugal folds at diaphragmatic hiatus

TypeIV:CompanionPt1withOther VisceraHerniatingonBaSw

Hiatal Hernia

Colon has also herniated


BaSw Fluoroscopy PACS, BIDMC

Nowletsapplywhatwehave learnedtoourpatientsimaging

OurpatientDB:FrontalCXR
The Stomach has herniated across the diaphragm and is now lying in the chest behind the heart

Retrocardiac Air-fluid Level

Frontal CXR

PACS, BIDMC

OurpatientDB:LateralCXR
The Stomach has herniated across the diaphragm and is now lying in the chest behind the heart Retrocardiac Air-fluid Level

Lateral CXR

PACS, BIDMC

OurpatientDB:BariumSwallow1
GEJ NG Tube Greater Curvature Lesser Curvature Inversion of curvatures suggests organoaxial rotation

Antrum/Pylorus Duodenum Body of stomach

BaSw Fluoroscopy

PACS, BIDMC

OurPatientDB:BariumSwallow2
No gastric distention is noted

Passage of Barium to small intestine


BaSw Fluoroscopy PACS, BIDMC

OurPatientDB:AxialCT+

Contrast-filled stomach next to the right lung that extends to the left chest and back below the diaphragm
Axial CT+ PACS, BIDMC

OurPatientDB:SagittalCT+

Contrast filled stomach in the chest, resting on the diaphragm

Sagittal CT+

PACS, BIDMC

OurpatientDB:CoronalCT+
Part of the bowel has also passed through the diaphragmatic hiatus Stomach protruding above the diaphragm and into the thoracic cavity
Coronal CT+ PACS, BIDMC

Now lets answer some questions about our patients hiatal hernia
1. Is it a type I or a type II-IV? Type II-IV (specifically II and IV), since we see that the GEJ remains intra-abdominal while both the stomach and another portion of bowel have herniated 2. Is there rotation or other signs of gastric volvulus? Yes. There is inversion of the greater and lesser curvature along the axis of the stomach, making this an organoaxial rotation. However, there is also free passage of barium and the stomach is not overly distended, indicating that no obstruction currently exists.

Patientreport
DBwasthoughttohaveaTypeII&IVhiatalhernia, complicatedbyorganoaxialrotation. Thesefindingscorroborateherclinicalpresentation ofretrosternalfullness,vomitingandpain. However,theeasypassageofanNGtube,non distendedstomach,visualizationofcontrastinthe smallbowel,andnoreboundtendernessonphysical examsuggestthatshedoesnotyethave strangulationofthestomach

OurPtDB:PostOpFrontalCXR
DBwasthusacandidate forsurgery,butnotan emergentprocedure Thefollowingdayshe underwentasuccessful laparoscopicrepairofthe hiatalhernia
Free air The stomach has been retuned to its anatomical position beneath the diaphragm

Frontal CXR

PACS, BIDMC

Review
HiatalHernia:herniationofabdominalcontents throughtheesophagealhiatusofthediaphragm FourtypesofHiatalHerniascategorizedby anatomicalrelationshipsofcriticalstructures BariumSwallowistheinitialtestofchoiceandoften allthatisneededtodiagnose ImportanttodistinguishbetweenTypeIandTypes IIIVbecausetheyhavedifferentmanagement IfTypeIIIV,lookforvolvulusandobstruction

Acknowledgements
Dr.ErnieYeh Dr.JayPahade Dr.YimingGao MariaLevantakis

References
1. 2. 3. 4. 5. 6. Abbara S. et Al, Intrathoracic Stomach Revisited. AJR 2003 181:403-414 Canon, C. et Al, Surgical Approach to Gastroesophageal Reflux Disease: What the Radiologist Needs to Know. Radiographics 2005; 25:1485-1499 Gordon, C. et Al, Review article: the role of the hiatus hernia in gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2004; 20:719-732 Jang, KM et Al, The Spectrum of Benign Esophageal Lesions: Imaging Findings. Korean J Radiol. 2002 199-210 Kahrilas, P. et Al, Approaches to the Diagnosis and Grading of Hiatal Hernia. Best Pract Res Clin Gastroenterol. 2008; 22(4) 601-616 Stylopoulous, N. Rattner, D., The History of Hiatal Hernia Surgery. Annals of Surgery. 2005; 241:185-193

Images:
Kahrilas,P. et Al. Best Pract Res Clin Gastroenterol. 2008; 22(4): 601-616. http://www.histopathology-india.net/stomach.jpg http://www.nlm.nih.gov/medlineplus/ency/presentations/100028_1.htm http://theodoregray.com/PeriodicTable/Elements/056/index.s7.html#sample3 Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414.