AJR 2003; 181:403-414
© American Roentgen Ray Society
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.
Received March 11, 2002;
accepted after revision January 30, 2003.
Address correspondence to S. Abbara.
Introduction
Surgical repair of paraesophageal hernias, even when a large portion of the
stomach has herniated intrathoracically, is now feasible using laparoscopic
techniques. Repair is possible with a low morbidity rate and good results,
prompting some surgeons to advocate corrective surgery electively in patients
who present with an intrathoracic stomach. Preoperative imaging studies, which
elucidate the abnormal anatomy, can be of considerable help in planning the
surgery. Radiologists thus need to be familiar with the anatomy and
complications of a paraesophageal hernia. Current textbooks of
gastrointestinal radiology cover this topic with little detail, and to our
knowledge, this subject has not been addressed in recent publications in the
radiology literature
[1–3].
Classification of Hiatal Hernias
In the surgical literature, hiatal hernias are divided into three or four
types (Fig. 1A,
1B,
1C,
1D). The intrathoracic stomach
may be found in paraesophageal hiatal hernias (types 2–4)
[4]. The paraesophageal hiatal
hernia (types 2–4) is an uncommon disorder, representing approximately
5% of all hernias occurring through the esophageal hiatus. An intrathoracic
stomach results from a paraesophageal hiatal hernia in which a substantial
portion of the stomach has herniated into the chest (Fig.
2A,
2B,
2C).
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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. 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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Type 1 Hiatal Hernia
The type 1 hiatal hernia is also called the sliding or axial hernia; it is
not considered paraesophageal. This type of hernia represents 95% of all
hiatal hernias. The esophagogastric junction is displaced into the chest
because of diffuse weakening and stretching of the phrenicoesophageal membrane
(Fig. 1A,
1B,
1C,
1D). The phrenicoesophageal
membrane is formed by the fused layers of the endothoracic fascia and the
endoabdominal fascia, which cover both sides of the diaphragm. The type 1
hiatal hernia may be associated with incompetence of the distal esophageal
sphincter, which can lead to the development of gastroesophageal reflux
disease.
Type 2 Hiatal Hernia
The type 2 hiatal hernia is called the paraesophageal or rolling hernia.
This type of hernia has a focal defect in the anterior and lateral aspect of
the phrenicoesophageal membrane. The gastric cardia and the esophagogastric
junction remain below the diaphragm (Figs.
1A,
1B,
1C,
1D,
3A,
3B, and
4A,
4B,
4C,
4D,
4E,
4F). The fundus is usually the
lead point of the herniation through the diaphragmatic defect. The rest of the
stomach may then migrate upward, leading to an intrathoracic stomach. The term
"parahiatal hernia" is reserved for rare cases in which some
fibers of the crura of the diaphragm are interposed between the esophagus and
the herniated stomach.
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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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Type 3 Hiatal Hernia
The type 3 hiatal hernia is called the "mixed" or
"compound" hiatal hernia. This type of hernia is the most common
form of paraesophageal hernias, combining the features of the type 2 and the
type 1 hernias. The phrenicoesophageal membrane is weakened and stretched. The
esophagogastric junction is displaced into the chest. Additionally, a defect
is present in the anterolateral portion of this membrane. Paraesophageal
herniation is usually large and is invariably associated with gastric rotation
(Figs. 1A,
1B,
1C,
1D,
2A,
2B,
2C,
5A,
5B, and
6A,
6B,
6C,
6D).
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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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Type 4 Hiatal Hernia
With marked widening of the diaphragmatic hiatus, other organs such as the
colon, omentum, small bowel, and liver can also herniate into the chest (Figs.
1A,
1B,
1C,
1D and
7A,
7B,
7C,
7D,
8A,
8B,
8C,
9A,
9B,
9C,
9D). When that occurs, the
hiatal hernia may be classified as type 4
[4]. This classification is not
universally used. Some consider this merely a variation of advanced type 3
gastric herniation.
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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. 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. 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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Anatomy of Gastric Rotation
As the stomach herniates into the chest, it also rotates (Fig.
2A,
2B,
2C). The most common rotation
is an anterior organoaxial rotation. In an organoaxial rotation, the stomach
rotates along its longitudinal axis. The more mobile, greater curvature moves
first in the anterior and then in the cephalad direction (Fig.
2B and
3A,
3B). As the herniation
progresses, the more distal parts of the stomach and even the pylorus become
involved in the rotation and intrathoracic displacement. Much less frequently,
the organoaxial rotation may be in a posterior direction (Fig.
9A,
9B,
9C,
9D).
The stomach can rotate along an axis that is 90° to the longitudinal
axis. Such rotation is called a mesenteroaxial rotation (Figs.
2C and
4A,
4B,
4C,
4D,
4E,
4F). This rotation may lead to
an upside-down stomach. Mesenteroaxial rotation of an intrathoracic stomach is
less common than organoaxial rotation. Mesenteroaxial rotation is more
frequently seen in patients with progression of a type 2 paraesophageal hiatal
hernia.
The term "gastric volvulus" is reserved for cases in which the
abnormal rotation has led to strangulation and obstruction
[5].
Clinical Features
Symptoms of a paraesophageal hernia vary significantly from the more common
sliding hiatal hernia. Patients with a small paraesophageal hernia are usually
asymptomatic. True dysphagia is usually not a presenting symptom, and symptoms
of reflux esophagitis are uncommon. As the disease progresses, food and air
may distend the herniated gastric segment. This distention causes discomfort
and chest pain that is usually most marked after a meal
[6]. Belching and retching may
lessen and relieve this discomfort. These symptoms may mimic angina and
myocardial infarction. With a large herniation, respiratory symptoms may be
prominent, especially postprandially. This is brought about by compression of
the lung and, in the mediastinum, by the filled intrathoracic stomach
[4,
7]. Anemia from occult bleeding
gastric ulcerations in the herniated stomach may be a presenting clinical
feature [7]. Other serious
gastric complications are less common and include volvulus, gangrene,
perforation, and recurrent pneumonia
[6,
8].
Diagnostic Workup
Hiatal hernias are frequently incidentally noted on conventional
radiography or CT performed for other reasons. Although a single fluid level
on a radiograph with the patient in the upright position merely indicates the
presence of a hiatal hernia, the presence of an intrathoracic stomach with
organoaxial or mesenteroaxial rotation can be suggested if a retrocardiac
"double fluid level" sign is seen
[9] (Fig.
9A,
9B,
9C,
9D). Multiplanar
reconstruction of CT images may aid in characterizing the herniation. No
convincing data exist as to how to work up incidentally noted hiatal hernias.
However, images from an upper gastrointestinal barium series best display the
anatomy and are usually required if surgical intervention is considered.
Esophagoscopy plays only a minor part in the diagnosis of paraesophageal
hernia [4]. Esophageal
shortening may be suggested by the presence of strictures in patients with
chronic inflammation such as Barrett's esophagus. However, in the absence of
such findings, esophageal shortening is difficult to predict.
Obstruction of Paraesophageal Hernia
The most serious complication of paraesophageal hernia is when the
low-grade obstruction progresses to incarceration and strangulation of the
stomach. This develops when the rotation of the herniated stomach leads to
volvulus or when the distended fundus prolapses into the abdomen (Fig.
10A,
10B,
10C,
10D). With further gastric
distention, several obstruction points develop. Thus, one may encounter
obstruction of the esophagus, the mid portion of the stomach, and the
duodenum, all at the level of the diaphragmatic hiatus. An abdominal
radiograph will show the enormously dilated gastric fundus, and the dilated
antrum can be detected on a radiograph of the chest. If this closed loop is
not promptly treated, it will progress to strangulation of the stomach
[6]. Patients with such
obstruction are in severe distress and will present with chest pain and
retching but will be unable to vomit, and it may not be possible to pass a
nasogastric tube. This constellation of symptoms is known as Borchardt's triad
[10]. The presence of a
retrocardiac double fluid level sign usually indicates the presence of an
intrathoracic stomach with chronic volvulus but does not indicate the presence
of obstruction.
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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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Surgical Perspective
The treatment of a symptomatic patient with an intrathoracic stomach is
usually surgery. If obstruction occurs, emergent surgery is indicated. Because
of the high morbidity and mortality rates that accompany complications, some
surgeons advocate elective surgery for asymptomatic patients if no other
medical disorders or contraindications are present
[8,
10]. Operative approaches may
be either through the abdomen or by a thoracotomy. The open laparotomy
approach has long been the standard, but more recently the laparoscopic repair
of these hernias has been refined and increasingly used
[10]. The general principles
of repair include reduction of the hernia into the abdomen, excision of the
hernia sac, closure of the large diaphragmatic hiatus, and gastropexy. The
results of elective repair of paraesophageal hernias or intrathoracic stomach
are generally good, with low morbidity and mortality rates
[7,
10].
Conclusion
Paraesophageal hernias are a common finding in diagnostic imaging studies;
yet the recognition of such hernias is important because morbidity and even
mortality may be avoided if the symptomatic patient is directed to surgery
before life-threatening complications occur.
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Introduction
Classification of Hiatal Hernias
