MyPACS.net: Radiology Teaching Files > Case 868937

previously visited PARAESOPHAGEAL HIATAL HERNIA
Contributed by: Dr Phillip Silberberg, Children's Hospital Omaha, Radiologist, Omaha Childrens, Creighton University and UNMC, Nebraska, USA.
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Discussion:

Paraesophageal hiatal hernias are uncommon, but they can be life threatening due to the increased risk for volvulus and incarceration.  The paraesophageal type is one of two major types of hiatal hernias along with the sliding hiatal hernia.   A vast majority of hiatal hernias are the sliding type. Hernias can occur in a congenitally large esophageal hiatus, can be acquired as a patient ages with the diaphragmatic crus loosening or can be due to an iatrogenic occurrence such as post-fundoplication.  In the pediatric population, congenital and iatrogenic causes are the most common.

In a paraesophageal hernia there is an upward dislocation of the gastric fundus alongside a normally positioned gastroesophageal junction (1). Structural deterioration or congenital defects in the phrenoesophageal membrane can lead to a paraesophageal hiatal hernia. The phrenoesophageal membrane is around the lower esophagus and helps to attach it to the diaphragm (2).  Most adult paraesophageal hiatal hernias are acquired, and are the result of deterioration of the fascial layers of the phrenoesophageal membrane.  Paraesophageal hernias that occur in children or infants are usually secondary to a congenital defect.  Children or adults who have undergone fundoplication are also another group that can acquire paraesophageal hernias.

Generally, since the herniated portion of the stomach in a paraesophageal hernia is not the gastric cardia (normal GE junction) as in a sliding hernia, there is little or no gastric content reflux unless a mixed type hiatal hernia is present.   Clinically, many patients with paraesophageal hernias are asymptomatic or have minor symptoms. Symptoms from obstruction can occur and include nausea, bloating, dysphagia, retching, or vomiting (1).  Postprandially, the patient may have epigastric pain and bloating or have shortness of breath and chest pain. Respiratory complications are common from compression of lung or from aspiration pneumonia.  Volvulus and incarceration are potentially life threatening complications of paraesophageal hernias.  Immediate intervention is required if a patient has severe epigastric pain, cannot vomit, and a nasogastric tube can not be placed, due to the high possibility of impending vascular compromise (1).

 

Imaging

 

            Plain chest radiographs can show a gastric air-fluid filled structure in the thorax behind the cardiac shadow. Opacity on the chest X-ray, especially in the costophrenic angle may be the only clue to diagnosis (3).  An upper GI barium swallow gives the diagnosis in most patients, but can be difficult if the hernia sac is empty or contains omentum (3). Generally, part of the stomach is seen in the thorax herniating anterior to the esophagus and the esophagogastric junction remains in the normal position below the diaphragm.  CT can help to establish a diagnosis in those an upper GI study is equivocal. CT will localize anatomy better and assesses herniated contents more accurately. CT is also helpful in evaluation of the affected lung. MRI is not routinely used in the diagnosis.  Ultrasound is used to rule out other causes of persistent vomiting in infants as a rapid test to tell between esophageal causes and duodenal causes. Ultrasound can detect a hiatal hernia as well. 

 

Treatment

 

Most surgeons believe that paraesophageal hiatal hernias should be corrected soon after diagnosis. This is because they are generally permanently incarcerated and the prevention of life-threatening complications is necessary, especially in children.  In adults, catastrophic complications tend to be less and elective treatment of asymptomatic patients may not always be necessary (3). Operative repair consists of reduction of the hernia sac, reduction of the stomach and hiatal defect repair (4). Surgical approach to repair can be transabdominal or transthoracic. Laparoscopic repair is also used, but is much more difficult than standard lapararoscopic Nissen fundoplication procedures.

References:


  1. M Hashemi, L Sillin, J Peters: Current concepts in the management of paraesophageal hiatal hernia. Journal of Clin Gastro, 1999;29(1):8-13
  2. A Khan, et al: Hiatal Hernia. http://www.emedicine.com/radio/topic337.htm, 2005
  3. M Imamoglu, A Cay, et al: Congenital paraesophageal hiatal hernia- pitfalls in the diagnosis and treatment. Journal of Pediatric surgery, 2005;40:1128-1133
  4. R Hendrickson, L Fenton, et al: Congenital paraesophageal hiatal hernia. Journ Amer College Surg, 2003;196(3):483
  5. A Jawad, A Al-Samarrai, et al: Congenital paraoesophageal hiatal hernia in infancy. Ped Surg Intern, 1998;13(2-3):91-94
  6. D. Darling: Hiatal hernia and Gastroesophageal reflux in infancy and childhood: analysis of the radiologic findings.  Amer Journ Roent, 1975;724-736



Contributed by:
M. Conor Simmons, 4th year medical student, Creighton University, Omaha, NE.    

Dr. Phillip Silberberg, Omaha Children's Hospital, Omaha, NE

Will Joekel

Benjamin Silberberg

Comments:
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Additional Details:

Case Number: 868937Last Updated: 09-05-2006
Anatomy: Gastrointestinal (GI)   Pathology: Iatrogenic
Modality: GIExam Date: 01-01-2000Access Level: Readable by all users

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