Figure 1
Conventional radiography of the chest
Conventional radiography of the chest (PA-view) shows a voluminous air containing cavity, in retrocardiac location.
Clinical History
Vomiting of large amounts of dark fluid and melena. Medical history of diverticulosis of the colon, minor esophageal peristalsis and a laparoscopic gastropexy 2 months previously for a diaphragmatic hiatal hernia.
Imaging Findings
The patient presented to the emergency room because of vomiting of large amounts of dark fluid and melena. His gastro-enterologic medical history was diverticulosis of the colon, minor esophageal peristalsis and a laparoscopic gastropexy 2 months previously for a diaphragmatic hiatal hernia.
Esophagogastroscopy, after aspiration of a major amount of fluid, revealed a combined hernia. Conventional chest radiography, CT scan of the thorax and contrast radiography of the upper gastrointestinal tract with Gastrografin® were performed, followed by retrograde opacification of the colon.
Conventional radiography of the chest (PA-view) (fig. 1) showed a voluminous air containing retrocardiac cavity. CT scan of the thorax(fig. 2) demonstrated a large retrocardiac herniation of the stomach; the air containing organ had a smooth mucosal pattern. On the left of the stomach there was a second air organ with peripheral haustrations corresponding to the transverse colon.
On contrast radiography of the upper gastrointestinal tract with Gastrografin® (fig. 3), the esophagogastric junction and the stomach were in intrathoracic location, in the posterior mediastinum. Retrograde opacification of the colon with Gastrografin® (fig. 4) showed opacification of a partially intrathoracically located transverse colon. The radiologic and endoscopic findings are characteristic for a type IV diaphragmatic hiatal hernia. As the patient had already been operated on, it could be considered a recurrent hernia.
Esophagogastroscopy, after aspiration of a major amount of fluid, revealed a combined hernia. Conventional chest radiography, CT scan of the thorax and contrast radiography of the upper gastrointestinal tract with Gastrografin® were performed, followed by retrograde opacification of the colon.
Conventional radiography of the chest (PA-view) (fig. 1) showed a voluminous air containing retrocardiac cavity. CT scan of the thorax(fig. 2) demonstrated a large retrocardiac herniation of the stomach; the air containing organ had a smooth mucosal pattern. On the left of the stomach there was a second air organ with peripheral haustrations corresponding to the transverse colon.
On contrast radiography of the upper gastrointestinal tract with Gastrografin® (fig. 3), the esophagogastric junction and the stomach were in intrathoracic location, in the posterior mediastinum. Retrograde opacification of the colon with Gastrografin® (fig. 4) showed opacification of a partially intrathoracically located transverse colon. The radiologic and endoscopic findings are characteristic for a type IV diaphragmatic hiatal hernia. As the patient had already been operated on, it could be considered a recurrent hernia.
Discussion
The most common hernia is the sliding hiatal hernia (type I hernia) in which the esophagogastric junction followed by the upper stomach has migrated through the esophageal hiatus into the posterior mediastinum. When symptoms occur they are caused by an incompetent lower esophageal sphincter mechanism with gastroesophageal reflux. In the native para-esophageal hernia (type II hernia) the esophagogastric junction remains in a normal intra-abdominal location while the fundus of the stomach protrudes into the thorax alongside the esophagus. An intrathoracic pressure phenomenon can occur. A para-esophageal hernia may be life-threatening. A hiatus hernia tends to enlarge with time so that the entire fundus and proximal antrum migrate into the posterior mediastinum with an intrathoracic displacement of the gastroesophageal junction. This combination of sliding and paraesophageal hernia has been labeled as type III hernia. When other intraabdominal organs such as omentum and bowel also herniate into the thorax, the anatomic condition is labeled as type IV hernia. Opinions differ regarding the nature of these large hernias, but the literature agrees that these large hernias need to be operated as soon as possible because of the great risk of incarceration or gastric volvulus. Distinction between different types of hernia is important considering the choice between surgical or non surgical therapy.
Recurrent hernias have an incidence rate of 11% and may develop between 4 days and 12 years after the original operation.
Recurrent hernias have an incidence rate of 11% and may develop between 4 days and 12 years after the original operation.
Differential Diagnosis List
Type IV diaphragmatic hiatal hernia
Final Diagnosis
Type IV diaphragmatic hiatal hernia
References
[1] Blamey S.: Classifying hiatus hernia. Does it make a difference to management? Aust Fam Physician, 1998, 27: 481-485. (PMID: 9648314)
[2] Ellis F. Jr.: Diaphragmatic hiatal hernias. Recognizing and treating the major types. Postgrad Med, 1990, 88: 113-114, 117-120, 123-124. (PMID: 1973284)
[3] Maziak D.E., Todd T.R., Pearson F.G.: Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg, 1998, 115: 53-60. (PMID: 9451045)
Case information
| URL: | https://www.eurorad.org/case/1728 |
| DOI: | 10.1594/EURORAD/CASE.1728 |
| ISSN: | 1563-4086 |
Figure 2
CT scan of the thorax
CT scan of the thorax demonstrates a large retrocardiac herniation of the stomach; the air containing organ has a smooth mucosal pattern. On the left of the stomach there is a second air organ with peripheral haustrations corresponding to the transverse colon.
Figure 3
Contrast radiography
On contrast radiography of the upper gastrointestinal tract with Gastrografin® (fig. 3), the esophagogastric junction and the stomach are located intrathoracically, in the posterior mediastinum.
Figure 4
Contrast radiography
Retrograde opacification of the colon with Gastrografin® shows opacification of a partially intrathoracically located transverse colon.
Conventional radiography of the chest
Conventional radiography of the chest (PA-view) shows a voluminous air containing cavity, in retrocardiac location.
CT scan of the thorax
CT scan of the thorax demonstrates a large retrocardiac herniation of the stomach; the air containing organ has a smooth mucosal pattern. On the left of the stomach there is a second air organ with peripheral haustrations corresponding to the transverse colon.
Contrast radiography
On contrast radiography of the upper gastrointestinal tract with Gastrografin® (fig. 3), the esophagogastric junction and the stomach are located intrathoracically, in the posterior mediastinum.
Contrast radiography
Retrograde opacification of the colon with Gastrografin® shows opacification of a partially intrathoracically located transverse colon.