Giancarlo Schiappacasse MD; Claudio Silva MD, MSc; Julia Alegría MDRadiology Department - Clínica Alemana de Santiago

Facultad de Medicina Clínica Alemana - UDD

Dealing with Diaphragmatic Hernias -Keypoints to a Proper Diagnosis

No disclosures

Purpose:

To illustrate MDCT findings of non-traumatic diaphragmatic hernia in adult patients.

To discuss relevant pointers for proper diagnosis of the different variants.

Muscular barrierseparating the thoracicand abdominal cavity.

Key role on breathingmechanics.

Disfunctions are associated with dyspnea,

may presenteventrations.

Diaphragm

Develops during weeks 4-12

Composed of four components:

Transverse septumPleuroperitoneal fold

Esophageal mesenteryMuscular body wall

RadioGraphics 2012; 32:E51–E70

Embryology

Diaphragmatic crura (arrows) merging on the midline

through the median arcuateligament (arrow head)

Axial upper abdomen CT imagesshow fixation of the lumbar portion through the lateral arcuate ligaments (arrows)

Diaphragmatic hernia is the protrusion of

abdominal content into the chest cavity through a

structural defect.

Defects are located among the muscular or

muscular-tendinous components.

Diaphragmatic Hernias

RadioGraphics 2012; 32:E51–E70

Accounts for fewer than 10% of congenital diaphragmatic hernias.In-utero failure to fuse the transverse septum to the lateral body.

90% are located on right side Well circumscribed mass with smooth borders may protude bowel in a

retrosternal location

Morgagni Hernia

One year-old patient, presenting with

vomiting. Admission chest x-ray reveals

protrusion of bowel gas in a retrosternal location

Anterolateral diaphragmatic defect

Hernia sac containing omental fat ± bowel

Most of the cases are diagnosed in adults

Morgagni Hernia

Non-contrast chest CT (coronal view with mediastinal window level), shows protrusion of a segment of transverse colon through

a Morgagni hernia (white arrows)

Complications of Morgagni Hernia65 year-old female patient, presents to the ER with

abdominal pain and leukocytosis.

CT shows an incarcerated bowel segment through a Morgagni hernia.

Symptomatic Morgagni hernia are rare, with only six cases of strangulated hernia described in the

literature1.Modi et al. Case Rep Surg. 2016;2016:2621383.

Bochdalek- type Congenital Hernia • 90% of congenital hernia • more common on the left side

• Pleuro-peritoneal fold fails to close near the 4th to 10th gestional week

• Etiology: poorly understood

• Mass effect on the fetal lung prevents normal development and leads to pulmonary hypoplasia

• Detected on prenatal US, fetal MRI is the best technique to characterize

Bochdalek- type Congenital Hernia

T2 WI: Multiple intrathoracic tubular high signal structures (bowel loops)

Fetal lung volume can be estimated prognostic value

Associated congenital anomalies in 25-50% of cases of CDH.

Up to 95% of stillborns with CDH have associated abnormalities.

Congenital heart disease is most common associated abnormality (VSD, ASD, PFO, tetralogy of Fallot, hypoplastic left heart)Approximately 8% have known genetic

abnormalities.

Repaired Bochdalek Hernia

Day 1: Pre-op Day 3: Post-op

Bochdalek Hernia in adultsProtrusion of abdominal contents through a

pleuro-peritoneal canal remnant. In adults, detection on MDCT prevalence range

from 0.17 to 1.5%114% are bilateral, studies report a right-sided

higher prevalence (68%)

1. Mullins ME et al. AJR 2001;177:363–366

Hiatal hernias

Netter

Sliding hiatus hernia

95% of all hiatal hernias

Gastroesophageal junction (GEJ) slides over the diaphragm, pulling a variable extent of the gastric fundus

into the mediastinum.

Hiatal hernias

5% of hiatal hernias

Stomach herniates through the esophageal hiatus and lies

besides the esophagus, with no displacement of the GEJ

Paraesophageal hiatus hernia

Hiatal hernias

HIATAL HERNIA CLASSIFICATION

c

b

The gastroesophageal junction (GEJ) has risen into the posterior mediastinum (a)

b and c: Coronal and axial view show the risen GEJ displacingthe descending aorta. Arrows show a dilated diaphragmatic

hiatus.

Hiatal Hernia type I

c

Stomach

Hiatal hernia

Abdominal CT with IV contrast (coronal view) shows a hiatal hernia. The gastro-esophageal junction has protruded to the posterior mediastinum.

Para-esophageal hernia (hernia type II)

GEJ stays in its position at the diaphragmatic hiatus, and the gastric fundus rises through

the hiatus (a).

Arrows in b show the widened crura with a normally situated GEJ (asterix)

In this case there is also an organ-axial and mesentero-axial gastric rotation, which

account for the gastric dilatation.

In organ-axial rotation the stomach rotates on its long axis (arrows on c, d, e) leaving the

major curvature anterior and superior

In mesentero-axial rotation, the stomach rotates on its short axis, leaving the gastric

antrum over the GEJ (d, e)

Image f shows intra-abdominal gastric dilation, with a antrum in the mediastinum, leaving the pylorus in the abdominal cavity.

A: antrum, E: esophagus

Hiatal hernia II

Stomach

Hiatal Hernia type IIDiaphragm

Paraesophageal hiatus hernia

Abdominal CT with IV contrast (coronal view) showing dilatation of intra-abdominal gastricportion, with protruded gastric antrum into the chest cavity. A: antrum. E: esophagus.

Contrast enhanced abdominal CT (axial and coronal view) shows a mixed hiatal hernia (type III), with protrusion of the GEJ (white line in a) into the chest and development of a para-esophageal hernia. Secondary proximal esophagus

dilatation. E: esophagus. A: gastric antrum

Hiatal Hernia type III

Hiatal hernia III

Stomach

In this case the pancreas has protruded through the esophageal hiatus. Diffuse atrophy with mainpancreatic duct dilatation, due to a hypovascular mass in the pancreatic head (white arrow).Surgery confirmed an adenocarcinoma. AE: splenic artery, VE: splenic vein, VB: biliary duct

Abdominal CT with IV contrast (coronal view) showing the

characteristic findings of a type IV hiatal hernia: widening of the

esophageal hiatus allowing passage of organs other than the stomach (colon, pancreas, liver,

etc) into the thoracic cavity.

Hiatal Hernia type IV

Stomach

Hiatal hernia IV

“Two HeartMediastinum”

Example of a gastric volvulus in an hiatal hernia, adopting a shape resembling

heart chambers, laying adjacent to the heart.

Suggested reading:

Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner CL, Godwin JD. Imaging of the diaphragm: anatomy and function. Radiographics. 2012; 32(2): E51-70.

Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek's hernia in a large adult population. AJR Am J Roentgenol. 2001; 177(2): 363-366.

Rosado-de-Christenson ML. Hiatal and Paraesophageal Hernia. In: Rosado-de-Christenson ML, Abbot J, Martinez-Jimenez S, editors. Diagnostic Imaging Chest. 2nd ed. Amisys; 2012.

Peterson CM, Anderson JS, Hara AK, Carenza JW, Menias CO. Volvulus of the gastrointestinal tract: appearances at multimodality imaging. Radiographics. 2009 Sep-Oct;29(5):1281-1293.

Hyun JJ, Bak YT. Clinical significance of hiatal hernia. Gut Liver. 2011 Sep;5(3):267-277.

Modi M, Kumar A, Mate A, Rege S. Strangulated Morgagni’s Hernia: A Rare Diagnosisand Management. Case Rep Surg. 2016;2016:2621383

Dealing with Diaphragmatic Hernias -Keypoints to a Proper Diagnosis

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