Professional Documents
Culture Documents
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)
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
QuickTime and a decompressor are needed to see this picture.
Kahrilas,P. et Al. Best Pract Res Clin Gastroenterol. 2008; 22(4): 601-616.
AnatomyReview:TheStomach
http://www.histopathology-india.net/stomach.jpg
AnatomyReview:Normal
GEJ is held within the abdomen by diaphragmatic crus
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
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
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
QuickTime and a decompressor are needed to see this picture.
MenuofTestsforImagingHiatalHernias
Endoscopy Manometry
ImagingModalities:BariumSwallow
BariumSwallow: thestudy ofchoiceforinitial evaluation Oftenallthatisneeded fordiagnosis Doubleorsinglecontrast (BaSO4 NaHCO3) Dynamicstudydone withfluoroscopy Importantbecause GEJmoveswith swallowing
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
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
QuickTime and a decompressor are needed to see this picture.
TypeIII:MixedHiatalHerniaonBaSw
GEJ is displaced above the diaphragm
TypeIV:CompanionPt1withOther VisceraHerniatingonBaSw
Hiatal Hernia
Nowletsapplywhatwehave learnedtoourpatientsimaging
OurpatientDB:FrontalCXR
The Stomach has herniated across the diaphragm and is now lying in the chest behind the heart
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
BaSw Fluoroscopy
PACS, BIDMC
OurPatientDB:BariumSwallow2
No gastric distention is noted
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+
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.