Hiatus hernia

Case contributed by MD Gaspar Alberto

Presentation

Screening

Patient Data

Age: 50 years
Gender: Male
CT

An round opacity is seen behind the heart. 

CT

MEDIASTINAL MASS

A. Anterior mediastinum mass:
Thymoma, teratoma, lymphoma, retrosternal thyroid, ascending aorta aneurysm, pericardiala cyst & cardiac abnormality,hematomas, parathyroid tumors, Morgagni hernias, mesenchymal tumors (lipoma, fibroma, hemangioma, etc.)

B. Middle mediastinum mass:
Lymph node disease: lymphoma, metastatic nodes, sarcoidosis, infection. Tumor of bronchus or tracheal, hiatal hernia,a bronchoenteric cysts, dilatation of aorta, pulmonary vessels.

C. Posterior mediastinum mass:
Neurogenic tumor, descending aorta aneurysm, Bochdalek hernia, abscess, extramedullary hematopoiesis, anterior meningocele, esophageal neoplasm, diverticula, HIATAL HERNIA, megaesophagus; thoracic spine: neoplasm, infectious spondylitis, hematoma/fracture.

CT

Hiatal hernia has often been called the "great mimic" because its symptoms can resemble many disorders. For example, a person with this problem can experience dull pains in the chest, shortness of breath (caused by the hernia's effect on the diaphragm), and heart palpitations (due to irritation of the vagus nerve).

In most cases however, a hiatal hernia does not cause any symptoms. The pain and discomfort that a patient experiences is due to the reflux of gastric acid, air or bile. While there are several causes of acid reflux, it does happen more frequently in the presence of hiatal hernia.

Case Discussion

Hiatal hernia (also called hiatus hernia and paraesophageal hernia) occurs when part of the stomach protrudes into the thoracic cavity through the esophageal hiatus of the diaphragm. Embryologic development of the diaphragm is a complex process; a number of defects result in a variety of possible congenital hernias through the diaphragm. A hernia may occur through a congenitally large esophageal hiatus; however, acquired hernias through the esophageal hiatus are more common. These hiatus hernias are classified either as sliding hernias or paraesophageal hernias (see the images below). Approximately 99% of hiatal hernias are sliding, and the remaining 1% are paraesophageal.

Plain chest radiographs may demonstrate a retrocardiac gas-filled structure. An upper GI barium series is the preferred examination in the investigation of suggested hiatal hernia and its sequelae. CT scans are useful when more precise cross-sectional anatomic localization is desired.

CT scanning is not routinely used in the diagnosis of a hiatal hernia, but it may be a useful for specific indications.

Hiatal hernias often are seen incidentally on CT scans obtained for other indications (see the image below). A hiatal hernia appears as a retrocardiac mass with or without an air-fluid level. The mass can usually be traced into the esophageal hiatus on sequential cuts. Herniation of omentum through the esophageal hiatus may result in an increase in fat surrounding the lower esophagus.

CT scanning is particularly useful in the accurate anatomic depiction of a totally intrathoracic stomach, especially in patients in whom volvulus of the stomach is suspected. CT scanning is also useful for staging purposes in patients in whom a carcinoma complicates a hiatal hernia. Dehiscence of diaphragmatic crura of more than 15 mm may be seen.

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Case information

rID: 14831
Case created: 30th Aug 2011
Last edited: 12th Jan 2016
Inclusion in quiz mode: Included

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