A hiatal hernia is a herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm. On an upright chest radiograph, a gastric bubble containing an air fluid level can be seen above the diaphragm, usually in the mid-chest in the retrocardiac region. There are four types of hiatal hernia (I—IV). Type I, or sliding hiatal hernia, accounts for >95% of cases. This is caused by laxity of the phrenoesophageal membrane, allowing a portion of the gastric cardia to herniate upward. Most of these are asymptomatic. Types II—IV hiatal hernias are varieties of paraesophageal hernias where the GE junction remains fixed while a portion of the stomach herniates through the esophageal hiatus and lies beside the esophagus.
The majority of patients with hiatal hernia are asymptomatic. When symptoms do occur, the most common symptoms are intermittent epigastric or substernal pain, postprandial fullness, nausea, and vomiting. Shortness of breath can occur due to diaphragmatic irritation and palpitations can occur due to vagus nerve irritation. If a hiatal hernia is noted on plain radiographs and further characterization of the defect is needed, the best radiographic modality is a barium swallow.
Figure 5.1 ▪ Hiatal Hernia.
A, B: Frontal radiograph demonstrates a midline retrocardiac rounded mass with an air fluid level (arrows). The lateral view confirms a rounded and air-filled middle mediastinal mass. This is the typical appearance for a hiatal hernia. The patient has had shoulder replacement surgery.
The natural progression of a type II, III, or IV hernia is progressive enlargement. They never regress spontaneously. For this reason, these are referred for surgical treatment, even in the absence of symptoms. Complications of an enlarging hernia include gastric volvulus, torsion, bleeding, incarcerated hernia pouch, and respiratory complications from mechanical lung compression. Type I hernias rarely require any intervention.
Figure 5.2 ▪ Hiatal Hernia.
A, B: Frontal radiograph demonstrates a midline retrocardiac rounded mass with an air fluid level. The lateral view confirms a rounded and air-filled middle mediastinal mass. This is the typical appearance for a hiatal hernia.
Most hiatal hernias are asymptomatic. If patients present with GERD symptoms, optimize PPI and H2 blocker therapy prior to referral for surgical management.
Barium swallow is the follow-up study of choice, if required.
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