Diaphragmatic Hernia

Diaphragmatic Hernia
Marc Michael M. Dela Cruz, MD

Diaphragmatic Hernias
• Non-traumatic
• Congenital
• Acquired
• Traumatic
Diaphragmatic Hernia – Non-traumatic
• Esophageal hiatus (Esophageal
hiatal hernia)
• Pleuroperitoneal hiatus
(Bochdalek’s hernia)
• Parasternal hiatus (Morgagni’s
hernia)
Esophageal Hiatal Hernia
• Most common
• Herniation of a portion of the stomach through the esophageal hiatus
• Usually seen as incidental asymptomatic masses on chest radiographs
• Some patients may have symptoms:
• Gastroesophageal reflux
• Severe pain
• Strangulation of the herniated stomach
• Rarely
Esophageal Hiatal Hernia
• Seen projecting behind the heart on frontal chest radiographs in the
immediate supradiaphragmatic region of the posterior mediastinum
• An air–fluid level may be seen in the hernia
• An esophagram is confirmatory
• CT shows widening of the esophageal hiatus and depicts the contents
of the hernia sac, which often include stomach, omental fat, and,
rarely, ascitic fluid.
Types of Esophageal Hiatal Hernia
Type 1: Sliding hiatal hernia (~95%)
Type 2: Rolling (Paraesophageal) hiatal hernia with the gastro-esophageal junction in a normal position
Type 3: Mixed or compound type, paraesophageal hiatal hernia with displaced gastro-esophageal
junction
Type 4: Mixed or compound type hiatal hernia with additional herniation of viscera
Sliding Hiatal Hernia
• Gastro-esophageal junction (GEJ) is usually
displaced >2 cm above the esophageal hiatus.
• Esophageal hiatus is often abnormally widened
to 3-4 cm (the upper limit of normal is 1.5 cm).
• Under fluoroscopy, if >3 gastric folds are seen
above the hiatus, this is suggestive of a sliding
hiatus hernia.
• Gastric fundus may also be displaced above the
diaphragm and present as a retrocardiac mass
on a chest radiograph.
• Presence of an air-fluid level in the mass
suggests the diagnosis.
• Small, sliding hiatus hernias commonly reduce in
the upright position.
Rolling (Paraesophageal) Hiatal Hernia
• Much less common than the
sliding type.
• GEJ remains in its normal
location while a portion of
the stomach herniates above
the diaphragm.
Mixed Rolling and Sliding Hiatal Hernia
• Mixed or compound hiatal hernia is
the most common type of
paraesophageal hernia.
• GEJ is displaced into the thorax with
a large portion of the stomach,
which is usually abnormally rotated.
• Large paraesophageal hernias, with
most of the stomach in the thorax,
increase the risk for complications
such as volvulus, obstruction, and
ischemia.
Bochdalek Hernia
• Foramen of Bochdalek
• Defect in the hemidiaphragm at the site of the embryonic
pleuroperitoneal canal.
• Neonates - Large hernias through the Bochdalek
foramen present with hypoplasia of the ipsilateral lung
and respiratory distress.
• Adults - Small hernias through this foramen are
common and are predominantly seen on the left side,
presumably because of the protective effect of the liver,
which prevents herniation of right infradiaphragmatic
fat through the right foramen of Bochdalek.
• The hernia typically appears as a posterolateral mass
above the left hemidiaphragm, although it can occur
anywhere along the posterior diaphragmatic surface.
• CT shows the diaphragmatic defect with herniation of
retroperitoneal fat, omentum, spleen, or kidney.
Bochdalek Hernia
Morgagni’s Hernia
• A defect in the parasternal portion of the
diaphragm, the foramen of Morgagni, is the least
common type of diaphragmatic hernia.
• A Morgagni hernia is invariably right sided and
appears as an asymptomatic cardiophrenic angle
mass.
• The diagnosis is made by noting herniation of
omental fat, liver, or transverse colon through the
paracardiac portion of the right hemidiaphragm on
CT scans through the lung bases.
• The presence of omental vessels within a fatty
paracardiac mass is diagnostic.
• Coronal CT can demonstrate the diaphragmatic
defect, distinguishing this entity from partial
eventration of the hemidiaphragm.
Traumatic Hernia
• Traumatic herniation of abdominal contents through a tear or rupture
of the central or posterior aspect of the hemidiaphragm may follow
blunt thoracoabdominal trauma or penetrating injury.
• The left side is affected in more than 90% of cases because the liver
dissipates the traumatic forces and protects the right hemidiaphragm
from injury.
• Radiographically, the diagnosis should be suspected when the left
hemidiaphragmatic contour is indistinct or elevated or when gas-filled
loops of bowel or stomach are seen in the left lower thorax following
severe trauma.
Traumatic Hernia
• Early diagnosis is often difficult because associated thoracic and abdominal injuries may obscure the
clinical and radiographic findings.
• The diagnosis is often made after the traumatic episode, with symptoms caused by intestinal
obstruction with strangulation (pain, vomiting, fever), compression of the left lung (cough, dyspnea,
chest pain), or as an incidental finding, particularly if only fat and no viscus has herniated through
the defect.
• In addition to the stomach, the small intestine, colon, omentum, spleen, kidney, fat, and the left lobe
of the liver can also herniate through the defect.
• The diagnosis is usually made by CT demonstrating bowel herniating into the thorax through a
constricting diaphragmatic defect.
• The resultant narrowing or “waist” of the herniated intestine as it traverses the diaphragmatic defect
differentiates a hernia from simple diaphragmatic elevation.
• Coronal and sagittal CT reconstructions can characterize the herniated tissues and detect associated
• visceral injuries.
Traumatic Hernia
• In addition to the detection of intrathoracic herniation of abdominal contents, CT can usually depict
the diaphragmatic defect, even in the absence of visceral herniation.
• Other CT findings suggestive of traumatic diaphragmatic injury include thickening or retraction of
the diaphragm away from the traumatic injury, a narrowing or waist of the diaphragm on the
herniated viscus (“collar” or “waist” sign) and contact between the posterior ribs and the liver
(right-sided injury) or stomach (left-sided injury), termed the “dependent viscera” sign.
Traumatic Hernia
References:
• Fraser's Synopsis of Diseases of the Chest 3rd Edition
• Brant - Fundamentals of Diagnostic Radiology - 5th Edition
• Radiopedia
Thank You

Diaphragmatic Hernia

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Diaphragmatic Hernia

Uploaded by

Copyright:

Available Formats

Diaphragmatic Hernia

Marc Michael M. Dela Cruz, MD

You might also like