August 2003, VOLUME 181
NUMBER 2

Recommend & Share

August 2003, Volume 181, Number 2

Pictorial Essay

Intrathoracic Stomach Revisited

+ Affiliations:
1Department of Radiology, Georgetown University Medical Center, 3800 Reservoir Rd., N.W., Washington, DC 20007.

2Present address: Department of Radiology, CIMIT, Massachusetts General Hospital, Ste. 400, 100 Charles River Plaza, Boston, MA 02114.

3Department of Surgery, Georgetown University Medical Center, Washington, DC 20007.

Citation: American Journal of Roentgenology. 2003;181: 403-414. 10.2214/ajr.181.2.1810403

Next section

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 [13].

Classification of Hiatal Hernias
Previous sectionNext section

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).

figure
View larger version (33K)
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).

figure
View larger version (41K)
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.

figure
View larger version (37K)
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.

figure
View larger version (44K)
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.

figure
View larger version (67K)
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).

figure
View larger version (32K)
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.

figure
View larger version (25K)
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.

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.

figure
View larger version (138K)
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.

figure
View larger version (67K)
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.

figure
View larger version (144K)
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.

figure
View larger version (164K)
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.

figure
View larger version (172K)
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.

figure
View larger version (163K)
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.

figure
View larger version (159K)
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.

figure
View larger version (37K)
Fig. 4F. —Type 2 paraesophageal hernia with redescending of fundus in 64-year-old man. Drawing shows anatomy of hiatal hernia.

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).

figure
View larger version (139K)
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.

figure
View larger version (156K)
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.

figure
View larger version (147K)
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).

figure
View larger version (158K)
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).

figure
View larger version (146K)
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).

figure
View larger version (209K)
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).

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.

figure
View larger version (148K)
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.

figure
View larger version (154K)
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.

figure
View larger version (160K)
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.

figure
View larger version (76K)
Fig. 7D. —Type 4 paraesophageal hernia in 49-year-old woman. Drawing of intrathoracic stomach shows slice positions of A, B, and C.

figure
View larger version (146K)
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])

figure
View larger version (157K)
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])

figure
View larger version (149K)
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).

figure
View larger version (165K)
Fig. 9A. —Type 4 paraesophageal hernia in 71-year-old woman. Anteroposterior chest radiograph shows air-filled viscera in right hemithorax.

figure
View larger version (144K)
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).

figure
View larger version (151K)
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).

figure
View larger version (165K)
Fig. 9D. —Type 4 paraesophageal hernia in 71-year-old woman. Radiograph of barium enema study confirms presence of herniated transverse colon.

Anatomy of Gastric Rotation
Previous sectionNext section

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
Previous sectionNext section

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
Previous sectionNext section

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
Previous sectionNext section

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.

figure
View larger version (182K)
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.

figure
View larger version (111K)
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.

figure
View larger version (146K)
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.

figure
View larger version (141K)
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.

Surgical Perspective
Previous sectionNext section

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
Previous sectionNext section

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.

Address correspondence to S. Abbara.

References
Previous sectionNext section
1. Eisenberg RL. Gastrointestinal radiology, 3rd ed. Philadelphia: Lippincott, 1996:166 –168 [Google Scholar]
2. Gerson DE, Lewicki AM. Intrathoracic stomach: when does it obstruct? Radiology 1976; 119:257 –264 [Google Scholar]
3. Sutton D. Textbook of radiology and imaging, 6th ed. New York: Churchill Livingstone,1998 : 810–811 [Google Scholar]
4. Naunheim KS, Creswell LL. Paraesophageal hiatal hernia. In: Shields TW, LoCicero J III, Ponn RB, eds. General thoracic surgery. Philadelphia: Lippincott Williams & Wilkins,2000 : 651–659 [Google Scholar]
5. Rorhmann CA, Nelson SW. Nonneoplastic diseases of the stomach. In: Freeny PC, Stevenson PW, eds. Margulis and Burhenne's alimentary tract radiology. St. Louis: Mosby, 1994:318 –372 [Google Scholar]
6. Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic stomach: presentation and results of operation. J Thorac Cardiovasc Surg 1993; 105:253 –259 [Google Scholar]
7. Hill LD. Paraesophageal hernia. In: Sabiston DC, Spencer FC, eds. Surgery of the chest. Philadelphia: Saunders,1995 : 1053–1058 [Google Scholar]
8. Wichterman K, Geha AS, Cahow CE, Baue AE. Giant paraesophageal hiatus hernia with intrathoracic stomach and colon: the case for early repair. Surgery 1979; 86:497 –506 [Google Scholar]
9. Scott RL, Felker R, Winer-Muram H, Pinstein ML. The differential retrocardiac air-fluid level: a sign of intrathoracic gastric volvulus. Can Assoc Radiol J 1986; 37:119 –121 [Google Scholar]
10. Wiechmann RJ, Ferguson MK, Naunheim KS, et al. Laparoscopic management of giant paraesophageal herniation. Ann Thorac Surg 2001; 71:1080 –1087 [Google Scholar]

Recommended Articles

Intrathoracic Stomach Revisited

Full Access, , , , , ,
American Journal of Roentgenology. 2003;181:551-559. 10.2214/ajr.181.2.1810551
Citation | Full Text | PDF (8918 KB) | PDF Plus (8987 KB) 
Full Access, , ,
American Journal of Roentgenology. 2003;181:309-316. 10.2214/ajr.181.2.1810309
Citation | Full Text | PDF (8837 KB) | PDF Plus (8937 KB) 
Full Access, , , , , , ,
American Journal of Roentgenology. 2003;181:561-567. 10.2214/ajr.181.2.1810561
Citation | Full Text | PDF (10666 KB) | PDF Plus (10751 KB) 
Full Access, ,
American Journal of Roentgenology. 2014;203:1192-1204. 10.2214/AJR.13.12386
Abstract | Full Text | PDF (1122 KB) | PDF Plus (1179 KB) | Erratum 
Full Access, , , ,
American Journal of Roentgenology. 2007;188:960-964. 10.2214/AJR.05.1209
Abstract | Full Text | PDF (682 KB) | PDF Plus (732 KB) 
Full Access, , , , ,
American Journal of Roentgenology. 2014;202:479-492. 10.2214/AJR.13.11463
Abstract | Full Text | PDF (1418 KB) | PDF Plus (1472 KB)