Intrathoracic Stomach Revisited
Suhny Abbara1,2,
Mohammed M. H. Kalan3 and
Ann M. Lewicki1
1 Department of Radiology, Georgetown University Medical Center, 3800 Reservoir
Rd., N.W., Washington, DC 20007.
2 Present address: Department of Radiology, CIMIT, Massachusetts General
Hospital, Ste. 400, 100 Charles River Plaza, Boston, MA 02114.
3 Department of Surgery, Georgetown University Medical Center, Washington, DC
20007.
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Fig. 1A. —Classification of hiatal hernias. Drawing of type 1 sliding hiatal
hernia shows esophagogastric junction (thick straight arrow)
displaced into thorax. Phrenicoesophageal membrane (arrowheads) is
circumferentially weakened and stretched without focal defect. Note
endothoracic and endoabdominal fascia (thin straight arrows) and
peritoneum (curved arrow).
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Fig. 1B. —Classification of hiatal hernias. Drawing of type 2 paraesophageal
or rolling hiatal hernia shows fundus and other portion of stomach
(straight arrow) herniated into chest through focal defect of
phrenicoesophageal membrane. Esophagogastric junction remains in normal
position at level of hiatus. Curved arrow indicates visceral peritoneum.
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Fig. 1C. —Classification of hiatal hernias. Drawing of type 3 compound or
mixed hiatal hernia shows displacement of esophagogastric junction, gastric
fundus, and body (arrow) into chest.
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Fig. 1D. —Classification of hiatal hernias. Drawing of type 4 compound hiatal
hernia with additional herniation of viscera shows other viscera herniated
into chest in addition to stomach. Some authors
[4] refer to this hernia as
type 4. However, this category is not universally recognized, and some
consider it to be variant of type 3.
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Fig. 2A. —Types of gastric rotation. Drawing defines long axis of organ. Three
anatomic landmarks anchor lesser curvature of stomach (shaded areas):
I = posterior attachment of lower esophagus, II = left gastric artery, and III
= retroperitoneal fixation of duodenum. Fixation sites are relatively immobile
and define long axis of stomach (dotted line).
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Fig. 2B. —Types of gastric rotation. Drawing illustrates organoaxial rotation
and shows type 3 hiatal hernia with anterior organoaxial rotation. Mobile
greater curvature moves anteriorly and superiorly so that in 180°
organoaxial rotation, mirror image of stomach is created with convex greater
curvature located above and to right of concave lesser curvature.
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Fig. 2C. —Types of gastric rotation. Drawing illustrates mesenteroaxial
rotation. Type 3 paraesophageal hernia with 180° mesenteroaxial rotation
is shown. Rotation of stomach is shown along axis (dotted lines)
perpendicular to organ's long axis (solid line). Mobile antrum and
duodenum move anteriorly and superiorly. Greater curvature remains on left.
Gastric fundus and antrum may be in reversed positions.
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Fig. 3A. —Type 2 paraesophageal hernia in 42-year old woman. (Reprinted with
permission from [2]) Radiograph
from upper gastrointestinal series shows gastric fundus and part of body
herniated into chest through anterior defect in phrenicoesophageal membrane.
Esophagogastric junction remains below diaphragm as seen on other views (not
shown) and during surgery. Herniated intrathoracic stomach is rotated 180°
in anterior organoaxial direction.
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Fig. 3B. —Type 2 paraesophageal hernia in 42-year old woman. (Reprinted with
permission from [2]) Drawing of
radiograph depicted in A shows gastric portion (dotted area)
is posterior wall of stomach. Two sites of torsion—one at
esophagogastric junction and other in body of stomach—are located at
level of diaphragmatic hiatus.
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Fig. 4A. —Type 2 paraesophageal hernia with redescending of fundus in
64-year-old man. Axial CT images obtained at level of left ventricle
(A) and diaphragmatic defect (B) show nasogastric tube
(arrow, A) in place with tip in fundus below diaphragm.
Esophagogastric junction is in normal position. Gastric antrum (A) and
duodenum are in thorax. Gastric fundus (F, B) is distended with
contrast material. Gastric fundus has either redescended into abdomen or there
is primary herniation of body and antrum only. Stomach has rotated
mesenteroaxially. Esophagus (short white arrow, B), duodenum
(long white arrow, B), and compressed gastric body (black
arrow, B) obtained at level of widened diaphragmatic hiatus are
shown.
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Fig. 4B. —Type 2 paraesophageal hernia with redescending of fundus in
64-year-old man. Axial CT images obtained at level of left ventricle
(A) and diaphragmatic defect (B) show nasogastric tube
(arrow, A) in place with tip in fundus below diaphragm.
Esophagogastric junction is in normal position. Gastric antrum (A) and
duodenum are in thorax. Gastric fundus (F, B) is distended with
contrast material. Gastric fundus has either redescended into abdomen or there
is primary herniation of body and antrum only. Stomach has rotated
mesenteroaxially. Esophagus (short white arrow, B), duodenum
(long white arrow, B), and compressed gastric body (black
arrow, B) obtained at level of widened diaphragmatic hiatus are
shown.
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Fig. 4C. —Type 2 paraesophageal hernia with redescending of fundus in
64-year-old man. Sagittal (C and D) and coronal (E)
multiplanar reconstructed MR images show site of gastric compression
(black arrows, D and E) and esophagus with nasogastric
tube (white arrows). Other images (not shown) revealed progress of
contrast material into small bowel. Compression atelectasis and effusion are
present at base of left lung. F = gastric fundus, A = gastric antrum.
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Fig. 4D. —Type 2 paraesophageal hernia with redescending of fundus in
64-year-old man. Sagittal (C and D) and coronal (E)
multiplanar reconstructed MR images show site of gastric compression
(black arrows, D and E) and esophagus with nasogastric
tube (white arrows). Other images (not shown) revealed progress of
contrast material into small bowel. Compression atelectasis and effusion are
present at base of left lung. F = gastric fundus, A = gastric antrum.
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Fig. 4E. —Type 2 paraesophageal hernia with redescending of fundus in
64-year-old man. Sagittal (C and D) and coronal (E)
multiplanar reconstructed MR images show site of gastric compression
(black arrows, D and E) and esophagus with nasogastric
tube (white arrows). Other images (not shown) revealed progress of
contrast material into small bowel. Compression atelectasis and effusion are
present at base of left lung. F = gastric fundus, A = gastric antrum.
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Fig. 4F. —Type 2 paraesophageal hernia with redescending of fundus in
64-year-old man. Drawing shows anatomy of hiatal hernia.
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Fig. 5A. —Type 3 paraesophageal hernia in 48-year-old man. (Reprinted with
permission from [2]) Selected
radiographs from upper gastrointestinal series show cranially displaced
gastroesophageal junction (arrows, A), fundus, and gastric
body, whereas antrum remains below diaphragm (A). Rotation of stomach
was observed during fluoroscopy. Point of twisting is shown (arrows,
B). Rotation was in anterior organoaxial direction.
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Fig. 5B. —Type 3 paraesophageal hernia in 48-year-old man. (Reprinted with
permission from [2]) Selected
radiographs from upper gastrointestinal series show cranially displaced
gastroesophageal junction (arrows, A), fundus, and gastric
body, whereas antrum remains below diaphragm (A). Rotation of stomach
was observed during fluoroscopy. Point of twisting is shown (arrows,
B). Rotation was in anterior organoaxial direction.
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Fig. 6A. —Type 3 paraesophageal hernia in 61-year-old woman. Axial CT images
were obtained with IV contrast material and no oral contrast material. Stomach
is displaced into chest. Normal esophagus (arrow, A) cannot be
traced caudally beyond esophagogastric junction (arrow, B),
which is also displaced. Stomach is empty and folded upon itself (C).
Diaphragmatic crura are separated by herniated stomach (arrowheads,
D), and hiatus measures 3.1 cm (normal size,  15 mm).
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Fig. 6B. —Type 3 paraesophageal hernia in 61-year-old woman. Axial CT images
were obtained with IV contrast material and no oral contrast material. Stomach
is displaced into chest. Normal esophagus (arrow, A) cannot be
traced caudally beyond esophagogastric junction (arrow, B),
which is also displaced. Stomach is empty and folded upon itself (C).
Diaphragmatic crura are separated by herniated stomach (arrowheads,
D), and hiatus measures 3.1 cm (normal size, 15 mm).
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Fig. 6C. —Type 3 paraesophageal hernia in 61-year-old woman. Axial CT images
were obtained with IV contrast material and no oral contrast material. Stomach
is displaced into chest. Normal esophagus (arrow, A) cannot be
traced caudally beyond esophagogastric junction (arrow, B),
which is also displaced. Stomach is empty and folded upon itself (C).
Diaphragmatic crura are separated by herniated stomach (arrowheads,
D), and hiatus measures 3.1 cm (normal size, 15 mm).
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Fig. 6D. —Type 3 paraesophageal hernia in 61-year-old woman. Axial CT images
were obtained with IV contrast material and no oral contrast material. Stomach
is displaced into chest. Normal esophagus (arrow, A) cannot be
traced caudally beyond esophagogastric junction (arrow, B),
which is also displaced. Stomach is empty and folded upon itself (C).
Diaphragmatic crura are separated by herniated stomach (arrowheads,
D), and hiatus measures 3.1 cm (normal size, 15 mm).
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Fig. 7A. —Type 4 paraesophageal hernia in 49-year-old woman. Axial CT images
obtained with oral contrast material show entire stomach herniated
intrathoracically (gastric fundus [F], body [B], antrum [A]). Esophagus is
identified (arrows, A and B), and esophagogastric
junction is seen (arrow, C). Duodenal bulb is also
intrathoracic (asterisk, C). Lesser curvature is inferior to
greater curvature and anterior to esophagus, and gastric fundus is located to
left of and lateral to gastroesophageal junction. This indicates anterior
mesenteroaxial rotation with resulting upside-down stomach. Additionally,
there is herniation of transverse colon (arrowhead, C),
indicating type 4 hernia.
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Fig. 7B. —Type 4 paraesophageal hernia in 49-year-old woman. Axial CT images
obtained with oral contrast material show entire stomach herniated
intrathoracically (gastric fundus [F], body [B], antrum [A]). Esophagus is
identified (arrows, A and B), and esophagogastric
junction is seen (arrow, C). Duodenal bulb is also
intrathoracic (asterisk, C). Lesser curvature is inferior to
greater curvature and anterior to esophagus, and gastric fundus is located to
left of and lateral to gastroesophageal junction. This indicates anterior
mesenteroaxial rotation with resulting upside-down stomach. Additionally,
there is herniation of transverse colon (arrowhead, C),
indicating type 4 hernia.
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Fig. 7C. —Type 4 paraesophageal hernia in 49-year-old woman. Axial CT images
obtained with oral contrast material show entire stomach herniated
intrathoracically (gastric fundus [F], body [B], antrum [A]). Esophagus is
identified (arrows, A and B), and esophagogastric
junction is seen (arrow, C). Duodenal bulb is also
intrathoracic (asterisk, C). Lesser curvature is inferior to
greater curvature and anterior to esophagus, and gastric fundus is located to
left of and lateral to gastroesophageal junction. This indicates anterior
mesenteroaxial rotation with resulting upside-down stomach. Additionally,
there is herniation of transverse colon (arrowhead, C),
indicating type 4 hernia.
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Fig. 7D. —Type 4 paraesophageal hernia in 49-year-old woman. Drawing of
intrathoracic stomach shows slice positions of A, B, and
C.
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Fig. 8A. —Type 4 paraesophageal hernia in 53-year-old man. Anteroposterior
chest radiograph shows inhomogeneously opacified right lower hemithorax.
(Reprinted with permission from
[2])
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Fig. 8B. —Type 4 paraesophageal hernia in 53-year-old man. Radiograph from
barium upper gastrointestinal series obtained with patient in prone position
shows that entire stomach is in intrathoracic location. Stomach has rotated
organoaxially 180° in anterior direction, as revealed on other images (not
shown). Air collection (arrow) in mediastinum indicates that other
viscera have herniated. (Reprinted with permission from
[2])
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Fig. 8C. —Type 4 paraesophageal hernia in 53-year-old man. Radiograph from
single-contrast barium enema obtained 4 years earlier than A and
B shows herniation of transverse colon through widened diaphragmatic
hiatus. Note air-filled stomach lateral to intrathoracic colon
(arrow).
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Fig. 9A. —Type 4 paraesophageal hernia in 71-year-old woman. Anteroposterior
chest radiograph shows air-filled viscera in right hemithorax.
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Fig. 9B. —Type 4 paraesophageal hernia in 71-year-old woman. Radiographs from
barium upper gastrointestinal series show barium-filled stomach is displaced
in its entirety into right chest (B). Fundus is located to right and
posterior to esophagogastric junction. Esophagogastric junction is displaced
anteriorly, and stomach projects posteriorly to esophagogastric junction.
These findings indicate posterior organoaxial rotation. Mesenteroaxial
component is also present because antrum is located cephalad to gastric
corpus. Differential barium level (arrows, B) shows typical
mechanism of double fluid level sign, as occasionally seen on chest
radiography (not shown). Additional air-containing viscera are seen in chest
(arrows, C).
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Fig. 9C. —Type 4 paraesophageal hernia in 71-year-old woman. Radiographs from
barium upper gastrointestinal series show barium-filled stomach is displaced
in its entirety into right chest (B). Fundus is located to right and
posterior to esophagogastric junction. Esophagogastric junction is displaced
anteriorly, and stomach projects posteriorly to esophagogastric junction.
These findings indicate posterior organoaxial rotation. Mesenteroaxial
component is also present because antrum is located cephalad to gastric
corpus. Differential barium level (arrows, B) shows typical
mechanism of double fluid level sign, as occasionally seen on chest
radiography (not shown). Additional air-containing viscera are seen in chest
(arrows, C).
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Fig. 9D. —Type 4 paraesophageal hernia in 71-year-old woman. Radiograph of
barium enema study confirms presence of herniated transverse colon.
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Fig. 10A. —Type 2 paraesophageal hernia with obstruction in 68-year-old woman.
(Reprinted with permission from
[2]) Early radiograph from
barium upper gastrointestinal series (A) and drawing of radiograph
(B) show fundus massively distended with air in abdomen. Nasogastric
tube is in place with tip in fundus. Orally administered barium outlines
esophagus with esophagogastric junction at hiatus. Small amounts of barium
have progressed into intraabdominal and intrathoracic (arrow)
portions of stomach.
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Fig. 10B. —Type 2 paraesophageal hernia with obstruction in 68-year-old woman.
(Reprinted with permission from
[2]) Early radiograph from
barium upper gastrointestinal series (A) and drawing of radiograph
(B) show fundus massively distended with air in abdomen. Nasogastric
tube is in place with tip in fundus. Orally administered barium outlines
esophagus with esophagogastric junction at hiatus. Small amounts of barium
have progressed into intraabdominal and intrathoracic (arrow)
portions of stomach.
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Fig. 10C. —Type 2 paraesophageal hernia with obstruction in 68-year-old woman.
(Reprinted with permission from
[2]) Follow-up (delayed)
radiograph from gastrointestinal series (C) and drawing of radiograph
(D) after more barium was given show that previously distended stomach
is now decompressed. This caused fundus to return to its intrathoracic
location. Paraesophageal hernia type 2, involving entire stomach with 180°
anterior rotation, is now shown. Torsion sites at esophagogastric junction and
distal antrum are visualized at level of hiatus. Nodular defects in wall of
fundus (arrows) are due to edema or mural hemorrhage.
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Fig. 10D. —Type 2 paraesophageal hernia with obstruction in 68-year-old woman.
(Reprinted with permission from
[2]) Follow-up (delayed)
radiograph from gastrointestinal series (C) and drawing of radiograph
(D) after more barium was given show that previously distended stomach
is now decompressed. This caused fundus to return to its intrathoracic
location. Paraesophageal hernia type 2, involving entire stomach with 180°
anterior rotation, is now shown. Torsion sites at esophagogastric junction and
distal antrum are visualized at level of hiatus. Nodular defects in wall of
fundus (arrows) are due to edema or mural hemorrhage.
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