胃扭转并发裂孔疝影像学表现

Hiatal Hernia with Complications  of  Gastric Volvulus Josué Zapata, HMS III Gillian Lieberman, MD January 25, 2010 Radiology Core Clerkship, BIDMC QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Agenda • Patient Report: DB • Differential diagnosis • Anatomy Review • What is a hiatal hernia? • Importance of proper diagnosis • Menu of tests • Radiologic examples • Return to diagnose DB • Resolution of case • Review Patient Report • HPI: DB is an 89 year old woman complaining  of several days of nausea, vomiting, and  retrosternal “heaviness” following meals • Has been unable to tolerate liquids or solids  since symptoms began • Now experiencing some episodes of acute  pain  Patient Report • PMH: known hiatal hernia, HTN, A. fib, CAD, DM  • PSH: Aortic valve replacement, ORIF R hip • Meds: Non‐contributory • Vitals: T: 100.0  HR: 89  BP: 124/67  RR: 20 02sat: 95%  on RA • Focused Physical Exam: No rebound  tenderness/guarding, +BS Exhaustive Differential Diagnosis • Myocardial Infarction • Aortic Dissection • Pulmonary Embolism • GERD • Achalasia • Diffuse esophageal spasm • Scleroderma • Chagas Disease • Esophageal mass (neoplasm, foreign body, bezoar, Schatzki’s) • Esophageal stricture or webs  • Diverticula (Zenker’s, Killian‐Jameson) • Hiatal Hernia Narrowed Differential Diagnosis • Hiatal Hernia • Achalasia • Diffuse esophageal spasm • Esophageal mass • Esophageal stricture or webs  • Diverticula (Zenker’s, Killian‐Jameson) For our teaching purposes we will  only be discussing what our patient  was ultimately found to have DB’s Final Diagnosis • Hiatal Hernia • Achalasia • Diffuse esophageal spasm • Esophageal mass • Esophageal stricture or webs  • Diverticula (Zenker’s, Killian‐Jameson) Hiatal Hernia Anatomy Review & BaSw: The Esophagus -24 cm muscular tube from pharynx to stomach -Described as “featureless” -A Ring: muscular ring at tubulovestibular junction -B Ring: Marker of GEJ Slide courtesy of Jay Pahade, MD BaSw Fluoroscopy Anatomy Review: The Diaphragm QuickTime™ and a decompressor are needed to see this picture. -Muscle layer that separates chest from abdomen -3 openings for the esophagus, aorta, & IVC -Esophageal hiatus is not perfectly tight so contents can pass through Kahrilas,P. et Al. Best Pract Res Clin Gastroenterol. 2008; 22(4): 601-616. Anatomy Review: The Stomach http://www.histopathology-india.net/stomach.jpg QuickTime™ and a decompressor are needed to see this picture. Anatomy Review: Normal http://www.nlm.nih.gov/medlineplus/ency/presentations/100028_1.htm QuickTime™ and a decompressor are needed to see this picture. GEJ is held within the abdomen by diaphragmatic crus Hiatal Hernia: The Basics • Definition: Herniation of abdominal contents through  the esophageal hiatus of the diaphragm • Thought to be due to muscle weakening and loss of  elasticity, particularly of phrenicoesophageal ligament • Incidence increase with age, 60% of population over age  60 affected  • Four types categorized by anatomical relationships of  critical structures – GEJ, Stomach, Diaphragmatic Hiatus, Other Viscera Hiatal Hernias: Type I • Sliding Hiatal Hernia (95%) – GEJ 2 cm or more above the  diaphragmatic hiatus – Clinically silent or presents  with GERD – Places the LES in the thorax,  thus eliminating the  bolstering affect of the crura  and exposing the LES to  negative intrathoracic  pressure – Dynamic action of swallowing  adds to difficulty of diagnosis Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414 Hiatal Hernias: Type II • Paraesophageal or  Rolling Hiatal Hernia – GEJ remains fixed in  proper location – Part of stomach  herniates into the chest – Clinically asymptomatic  or presents with  symptoms of substernal  pain, postprandial  fullness,  nausea/vomiting, and  SOB Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414 Hiatal Hernias: Type III • Mixed Hiatal Hernia – both GEJ and part of the  stomach herniates into  the chest – Clinically asymptomatic  or presents with  symptoms of substernal  pain, postprandial  fullness,  nausea/vomiting, and  SOB Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414 Hiatal Hernias: Type IV • Non‐Stomach Viscera  Herniates – Some debate about  name, some believe this  is a variation of a type 2  or 3 – Clinically asymptomatic  or presents with  symptoms of substernal  pain, postprandial  fullness,  nausea/vomiting, and  SOB Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414 Hiatal Hernias: Management • Type I is either asymptomatic or  associated with GERD and if so, typically  responds to medical management and is  only surgical in rare cases • Types II‐IV tend to expand over time and  have the ability to rotate and are therefore  typically reduced surgically Type II‐IV Hiatal Hernias: Major  Complications Visceral Rotation: – This can cause Gastric Volvulus and  subsequent strangulation of the stomach  (33%) • Surgical emergency due to potential for  ischemia • Borchardt’s Triad: Pain, Retching without  vomiting, Inability to pass NG tube (found in  70% of pts with strangulation) Diagrams of Gastric Volvulus QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Mesenteroaxial Rotation Organoaxial Rotation - Most Common Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414 Menu of Tests for Imaging Hiatal Hernias • BaSw: test of choice (see next slide) • CT: occasionally obtained to better characterize the  hernia in unclear cases or before surgery • Plain Film: diagnosis can be suggested by an air‐fluid  level in retrocardiac area on CXR or KUB – Often an incidental finding given the high prevalence of  hiatal hernia • Endoscopy  • Manometry Imaging Modalities: Barium Swallow QuickTime™ and a decompressor are needed to see this picture. • Barium Swallow: the study  of choice for initial  evaluation – Often all that is needed  for diagnosis – Double or single contrast  (BaSO4   NaHCO3 ) – Dynamic study done  with fluoroscopy • Important because  GEJ moves with  swallowing http://theodoregray.com/PeriodicTable/Elements/056/index.s7.html#sample3 How to evaluate the imaging • Hiatal Hernia diagnosis is based on anatomy: – Need to identify the GEJ, the stomach, and their  relationship to the diaphragmatic hiatus – Use clues such as the contour of esophagus which  should be “featureless” vs. rugae in stomach   – Type I: 2 cm rule‐ at least 2 cm between EGJ and   diaphragmatic hiatus to differentiate from  “physiologic herniation” – Type II‐IV: Gastric Volvulus‐ look for the NG tube,  distention, obstruction of flow, and inversion of  curvatures or other signs of rotation Type I: Sliding Hiatal Hernia on BaSw Kahrilas P. et Al Approaches to the Diagnosis and Grading of Hiatal Hernia. Best Pract Res Clin Gastroenterol. 2008 22(4):601-616 QuickTime™ and a decompressor are needed to see this picture. Gastric Rugae Diaphragm BaSw fluoroscopy Type II: Paraesophageal Hiatal  Hernia on CT QuickTime™ and a decompressor are needed to see this picture. NG Tube Illustrating the path of the esophagus and that the GEJ is below the diaphragm Gastric Antrum is protruding into the thorax Abbara S. et Al Intrathoracic Stomach Revisited. AJR 2003 181:403-414 CT Sagittal Type III: Mixed Hiatal Hernia on BaSw QuickTime™ and a decompressor are needed to see this picture. GEJ is displaced above the diaphragm A large part of the stomach has herniated as well Rugal folds at diaphragmatic hiatus Image Courtesy of Yiming Gao, MD BaSw fluoroscopy Type IV: Companion Pt 1 with Other  Viscera Herniating on BaSw BaSw Fluoroscopy PACS, BIDMC Hiatal Hernia Colon has also herniated Now let’s apply what we have  learned to our patient’s imaging Our patient DB: Frontal CXR Retrocardiac Air-fluid Level The Stomach has herniated across the diaphragm and is now lying in the chest behind the heart PACS, BIDMCFrontal CXR Our patient DB: Lateral CXR Retrocardiac Air-fluid Level The Stomach has herniated across the diaphragm and is now lying in the chest behind the heart PACS, BIDMCLateral CXR Our patient DB: Barium Swallow 1 NG Tube Greater Curvature Lesser Curvature Duodenum Body of stomach Antrum/Pylorus GEJ PACS, BIDMC Inversion of curvatures suggests organoaxial rotation BaSw Fluoroscopy Our Patient DB: Barium Swallow 2 Passage of Barium to small intestine No gastric distention is noted PACS, BIDMCBaSw Fluoroscopy Our Patient DB: Axial CT+ Contrast-filled stomach next to the right lung that extends to the left chest and back below the diaphragm PACS, BIDMCAxial CT+ Our Patient DB: Sagittal CT+ Contrast filled stomach in the chest, resting on the diaphragm PACS, BIDMCSagittal CT+ Our patient DB: Coronal CT+ Stomach protruding above the diaphragm and into the thoracic cavity Part of the bowel has also passed through the diaphragmatic hiatus PACS, BIDMCCoronal CT+ Now let’s answer some questions about our patient’s hiatal hernia 1. Is it a type I or a type II-IV? Type II-IV (specifically II and IV), since we see that the GEJ remains intra-abdominal while both the stomach and another portion of bowel have herniated 2. Is there rotation or other signs of gastric volvulus? Yes. There is inversion of the greater and lesser curvature along the axis of the stomach, making this an organoaxial rotation. However, there is also free passage of barium and the stomach is not overly distended, indicating that no obstruction currently exists. Patient report • DB was thought to have a Type II & IV hiatal hernia,  complicated by organoaxial rotation.   • These findings  corroborate her clinical presentation  of retrosternal fullness, vomiting and pain. • However, the easy passage of an NG tube, non‐ distended stomach, visualization of contrast in the  small bowel, and no rebound tenderness on physical  exam suggest that she does not yet have  strangulation of the stomach Our Pt DB: Post‐Op Frontal CXR • DB was thus a candidate  for surgery, but not an  emergent procedure • The following day she  underwent a successful  laparoscopic repair of the  hiatal hernia PACS, BIDMC The stomach has been retuned to its anatomical position beneath the diaphragm Free air Frontal CXR Review • Hiatal Hernia: herniation of abdominal contents  through the esophageal hiatus of the diaphragm • Four types of Hiatal Hernias categorized by  anatomical relationships of critical structures • Barium Swallow is the initial test of choice and often  all that is needed to diagnose • Important to distinguish between Type I and Types  II‐IV because they have different management • If Type II‐IV, look for volvulus and obstruction Acknowledgements • Dr. Ernie Yeh • Dr. Jay Pahade • Dr. Yiming Gao • Maria Levantakis References 1. Abbara S. et Al, Intrathoracic Stomach Revisited. AJR 2003 181:403-414 2. Canon, C. et Al, Surgical Approach to Gastroesophageal Reflux Disease: What the Radiologist Needs to Know. Radiographics 2005; 25:1485-1499 3. Gordon, C. et Al, Review article: the role of the hiatus hernia in gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2004; 20:719-732 4. Jang, KM et Al, The Spectrum of Benign Esophageal Lesions: Imaging Findings. Korean J Radiol. 2002 199-210 5. Kahrilas, P. et Al, Approaches to the Diagnosis and Grading of Hiatal Hernia. Best Pract Res Clin Gastroenterol. 2008; 22(4) 601-616 6. Stylopoulous, N. Rattner, D., The History of Hiatal Hernia Surgery. Annals of Surgery. 2005; 241:185-193 Images: Kahrilas,P. et Al. Best Pract Res Clin Gastroenterol. 2008; 22(4): 601-616. http://www.histopathology-india.net/stomach.jpg http://www.nlm.nih.gov/medlineplus/ency/presentations/100028_1.htm http://theodoregray.com/PeriodicTable/Elements/056/index.s7.html#sample3 Abbara S. et Al. Intrathoracic Stomach Revisited. AJR 2003 181:403-414. Hiatal Hernia with Complications of Gastric Volvulus Agenda Patient Report Patient Report Exhaustive Differential Diagnosis Narrowed Differential Diagnosis For our teaching purposes we will only be discussing what our patient was ultimately found to have DB’s Final Diagnosis Anatomy Review & BaSw: The Esophagus Anatomy Review: The Diaphragm Anatomy Review: The Stomach Anatomy Review: Normal Hiatal Hernia: The Basics Hiatal Hernias: Type I Hiatal Hernias: Type II Hiatal Hernias: Type III Hiatal Hernias: Type IV Hiatal Hernias: Management Type II-IV Hiatal Hernias: Major Complications Diagrams of Gastric Volvulus Menu of Tests for Imaging Hiatal Hernias Imaging Modalities: Barium Swallow How to evaluate the imaging Type I: Sliding Hiatal Hernia on BaSw Type II: Paraesophageal Hiatal Hernia on CT Type III: Mixed Hiatal Hernia on BaSw Type IV: Companion Pt 1 with Other Viscera Herniating on BaSw Now let’s apply what we have learned to our patient’s imaging Our patient DB: Frontal CXR Our patient DB: Lateral CXR Our patient DB: Barium Swallow 1 Our Patient DB: Barium Swallow 2 Our Patient DB: Axial CT+ Our Patient DB: Sagittal CT+ Our patient DB: Coronal CT+ Now let’s answer some questions about our patient’s hiatal hernia Patient report Our Pt DB: Post-Op Frontal CXR Review Acknowledgements References