CASE 3162 Published on 05.01.2007

Sliding oesophageal hiatal hernia

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Oliveira P, Rodrigues H, Seco M, Soares P, Ilharco J

Patient

45 years, male

Categories
No Area of Interest ; Imaging Technique Digital radiography
Clinical History
A 45-year-old male presented with a retrosternal and epigastric burning pain which appeared after he had had eaten and while sleeping or lying in a recumbent position.
Imaging Findings
A 45-year-old male presented with a retrosternal and epigastric burning pain which appeared after he had had eaten and while sleeping or lying in a recumbent position. This distress was relieved by drinking water or other liquids, by antacids, or, in many instances, by standing or sitting. The pain was very similar to that of angina pectoris. On doing an upper gastrointestinal series, it was clear that a portion of the stomach was protruding upward through the oesophageal hiatus.
Discussion
Hiatal hernias can be classified into two types: a) an axial hernia exists when a loculus of the stomach and the gastric cardia pass through the hiatus into the thorax; b) a paraoesophageal hernia exists when a portion of the stomach herniates through the hiatus, but cardia remains normally located. Only 1% of these are paraoesophageal. Axial hernias may be fixed in position but generally slide in and out of the thorax. Sliding hernias indicate that there is a stretching or rupture of the phrenicoesophageal membranes that normally tether the distal oesophagus at the hiatus. The most frequent complications of paraesophageal hernia are haemorrhage, incarceration, obstruction, and strangulation. The herniated portion of the stomach often becomes congested, and bleeding occurs from erosions of the mucosa. Obstruction may occur, most often as a result of torsion and angulation at the esophagogastric junction. A radiological examination is the best method for finding out whether hiatal hernia is present. An adequate examination when done must include inspection of the oesophageal function as well as its morphology and obtaining a maximal oesophageal distension during the examination. Distension is enhanced by the rapid delivery of barium or impedance of oesophageal outflow by Valsalva manoeuvre. The best practice to reveal a hernia is the double contrast exam with the patient in the horizontal position. The hernia is sometimes only visible, when the bolus passes through the esophagogastric junction (supine usually but not always better than prone). Most patients (80%) with a clinically significant reflux have a sliding hiatal hernia. In these patients, the cardioesophageal junction and the fundus of the stomach are displaced upward into the posterior mediastinum, exposing the lower oesophageal sphincter to intrathoracic pressure. Normally, the intra-abdominal position of the lower oesophagus causes it to be exposed to higher external pressures, and a loss of this position accounts for the close association of reflux with hiatal hernias.
Differential Diagnosis List
Sliding oesophageal hiatal hernia.
Final Diagnosis
Sliding oesophageal hiatal hernia.
Case information
URL: https://www.eurorad.org/case/3162
DOI: 10.1594/EURORAD/CASE.3162
ISSN: 1563-4086