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Incidentalfindingofahiatusherniaonchestxray
andCTscan

TheAPchestxray(A)showsahiatushernia(asterisk)withanair
fluidlevel(arrows).Alateralchestxray(B)confirmsahiatushernia
(asterisk)andanairfluidlevelinthehernia(arrows).ACTscanin
theaxialplane(C)showscontrastinthehiatushernia(asterisk).
AP:anteroposteriorCT:computedtomography.
Graphic90295Version2.0

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Esophagealshorteningduringswallow

(A)BeforeswallowClipBmarksthepositionofthesquamocolumnar
junction(SCJ),35mmdistaltotheanchorpointonthevertebral
bodyclipAisaffixedtotheesophagealmucosa31mmproximally.
ClipmovementsarereferencedtopointVonthevertebralcolumn.
(B)Atthetimeofmaximalesophagealshorteningduringswallow,clip
Bis20mmdistaltopointVandthedistancebetweenclipsAandBis
reducedto22mm,indicativeof29percentshortening.
(C)Aselongationproceeds,firstbothclipsdescend,afterwhichclipB
descends,stretchingtheABsegmentbacktoitsinitiallength.
(D)Afterswallowrecoverytonormal.
Withpermissionfrom:KahrilasPJ,WuS,LinS,etal.Attenuationof
esophagealshorteningduringperistalsiswithhiatushernia.Gastroenterology
1995109:1818.
Graphic61193Version4.0

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Anatomicfeaturesofslidinghiatushernia

Representationoftheanatomicfeaturesofaslidinghiatushernia
viewedradiographicallyduringswallowing.The"A"ringisamuscular
ringvisibleduringswallowingwhichdemarcatesthesuperiormarginof
theloweresophagealsphincter.The"B"ringatthesquamocolumnar
junctionispresentinonlyabout15percentofindividualsitpermits
accuratedivisionofthephrenicampullaintotheesophagealvestibule
(AringtoBring)andtheslidinghiatushernia(Bringtothe
subdiaphragmaticstomach).Rugalfoldstraversingthehiatussupport
theconvictionthataportionofthestomachissupradiaphragmatic.
Reproducedwithpermissionfrom:KahrilasPJ.Hiatusherniacausesreflux:
Factorfiction?Gullet19933(Suppl):21.
Graphic72582Version4.0

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GastriccomponentoftheLES

Theproximalmarginoftheloweresophagealsphincter(LES)extends
uptoandashortdistanceproximaltothesquamocolumnarjunction
(notshown).ThedistalmarginoftheLESismoredifficulttodefine
butcarefulanatomicstudiessuggestthatitiscomposedofelements
ofthegastricmusculature,theopposingclaspandslingfibersofthe
gastriccardia.
Adaptedfrom:LiebermannMeffertD,AllgwerM,SchmidP,BlumAL.Muscular
equivalentoftheloweresophagealsphincter.Gastroenterology197976:31.
Graphic69389Version4.0

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Slidingversusparaesophagealhiatushernia

Distinctionbetweenaslidinghiatushernia(typeI)andparaesophagealhernia
(typeII).WithtypeIhernia,theleadingedgeisthegastriccardiawhilewith
typeIIitisthegastricfundus.Thesquamocolumnarjunctionmaintainsitsnative
positionintheparaesophagealherniawhileitisdisplacedupwardwiththe
slidinghernia.
SC:squamocolumnar.
KahrilasPJ,KimHC,PandolfinoJE.Approachestothediagnosisandgradingofhiatal
hernia.BestPractResClinGastroenterol200822:601.
KWWSZZZXSWRGDWHFRPFRQWHQWVKLDWXVKHUQLD"WRSLF.H\ *$67) HODSVHG7LPH0V  VRXUFH VHDUFKBUHVXOW VHDUFK7HUP KHUQLDKLDWDO VHOHFWH





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Graphic62190Version5.0

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Bariumswallowinapatientwithahiatushernia

(A)Normalbariumswallowshowingthegastroesophagealjunction
(arrow)isatthelevelofthediaphragm(arrowhead)andthegastric
folds(dashedarrow)areatthesamelevelasthediaphragm.
(B)Bariumswallowshowingaslidinghiatushernia(asterisk).The
gastroesophagealjunction(arrow)isabovethediaphragm
(arrowhead)andthegastricfolds(dashedarrow)areabovethe
diaphragm.
(C)Bariumswallowshowingaparaesophagealhernia(asterisk).The
gastroesophagealjunction(arrow)isbelowthediaphragm
(arrowhead).
Graphic90296Version2.0

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BariumswallowinapatientwithatypeIIIparaesophagealhernia

(A)Achestxraypriortocontrastadministrationshowsthenasogastrictubecoiledinthe
chest(arrows).
(B)Followingbariumadministrationthroughthenasogastrictube,thegastroesophageal
junctionandtheentirestomacharenotedwithinthechest.
Graphic90299Version2.0

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Bariumswallowandcomputedtomography(CT)scaninapatient
withatypeIVparaesophagealhiatushernia

(A)Abariumswallowshowingtheentirestomachwithinthechest(asterisk).The
gastroesophagealjunction(arrow)isabovethediaphragm(arrowhead)andthefirstpartof
theduodenum(dashedarrow)isatthelevelofthediaphragm.
(B)ACTscanthroughthelowerchestshowingtheherniatedstomach(asterisk)and
portionsofthecolonwithinthehernialsacinthechest(arrow).
Graphic90300Version2.0

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Progressiveanatomicdisruptionofthe
gastroesophagealjunction

Endoscopicappearanceandcorrespondingthreedimensional
representationoftheprogressiveanatomicdisruptionofthe
gastroesophagealjunctionasoccurswithdevelopmentofatypeI
hiatushernia.InthegradeIconfiguration,aridgeofmusculartissue
iscloselyapproximatedtotheshaftoftheretroflexedendoscope.
WithagradeIIconfigurationtheridgeoftissueisslightlylesswell
definedandtherehasbeenslightoraddisplacementofthe
squamocolumnarjunctionalongwithwideningoftheangleofHis.In
thegradeIIIappearancetheridgeoftissueatthegastricentrywayis
barelypresentandthereisoftenincompleteluminalclosurearound
theendoscope.Note,however,thatthisisnotahiatalherniabecause
KWWSZZZXSWRGDWHFRPFRQWHQWVKLDWXVKHUQLD"WRSLF.H\ *$67) HODSVHG7LPH0V  VRXUFH VHDUFKBUHVXOW VHDUFK7HUP KHUQLDKLDWDO VHOHFWH





+LDWXVKHUQLD

thesquamocolumnarjunctionisnotdisplacedaxiallyinthe
endoscopicphotograph.WithgradeIVdeformity,nomuscularridgeis
presentatthegastricentry.Thegastroesophagealareastaysopenall
thetime,andsquamousepitheliumofthedistaloesophaguscanbe
seenfromtheretroflexedendoscopicview.Ahiatusherniaisalways
presentwithgradeIVdeformity.
Reproducedfrom:BredenoordAJ,PandolfinoJE,SmoutAJ.Gastro
oesophagealrefluxdisease.Lancet2013381:1933.Illustrationusedwith
thepermissionofElsevierInc.Allrightsreserved.
Graphic85907Version1.0

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InteractionofhiatusherniasizeandLESpressureon
reflux

Modelshowingtherelationshipbetweenhiatusherniasize,loweresophageal
sphincter(LES)pressure,andrefluxscore.Therefluxscoreincreasedwith
increasingherniasizeandlowerLESpressure,bothofwhichwererequiredfor
markedreflux.
Reproducedwithpermissionfrom:SloanS,RademakerAW,KahrilasPJ.Determinantsof
gastroesophagealjunctionincompetence:hiatalhernia,loweresophagealsphincter,or
both?AnnInternMed1992117:977.
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Rerefluxwithhiatushernia

Depictionofaradionuclideacidclearancestudyinasubjectwitha
hiatushernia.Fifteensecondsaftertheinjectionofa15mLbolusof
0.1NHCllabeledwith200microcuriesof99mTcsulfurcolloid,
subjectsswallowedevery30seconds.Theverticalaxisrepresentsthe
regionfromthesternalnotchtothestomach.Thehorizontalaxisis
thetimescale.Theradioactivityisrepresentedbytheblackareaand
noradioactivityisrepresentedbytheabsenceofblackcolor.Soon
afterinjection,theradioactivityappearsinthestomach.However,
thereisrefluxofisotopeintotheesophagusfollowedbyclearanceof
theisotopeduringeachofthefirstthreeswallows.
Reprintedwithpermissionfrom:MittalRK,LangeRC,McCallumRW.
Identificationandmechanismofdelayedesophagealacidclearanceinsubjects
withhiatushernia.Gastroenterology198792:130.Copyright1987by
AmericanGastroenterologicalAssociation.Thismaterialmaynotbe
reproducedordistributedinanyformorbyanymeanswithouttheproper
writtenpermissionofthepublisher.
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Volvulusinhiatushernia

Paraesophagealherniasareassociatedwithabnormallaxityof
structuresnormallypreventingdisplacementofthestomach,the
gastrosplenicandgastrocolicligaments.Astheherniaenlarges,the
greatercurvatureofthestomachrollsupintothethorax.Becausethe
stomachisfixedatthegastroesophagealjunction,theherniated
stomachtendstorotatearounditslongitudinalaxis,resultinginan
organoaxialvolvulus(toppanels)infrequently,rotationoccurs
aroundthetransverseaxisresultinginamesenteroaxialvolvulus
(bottompanels).
Adaptedfrom:PeridikisG,HinderRA.Paraesophagealhiatalhernia.In:Hernia,
NyhusLM,CondonRE(Eds),JBLippincott,Philadelphia1995.p.544.
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Bariumswallowandcomputedtomography(CT)scaninapatient
withaparaesophagealhernia

(A)Abariumswallowshowingaparaesophagealhernia(asterisk).Thegastroesophageal
junction(arrow)isatthelevelofthediaphragm(arrowhead).
(B)AnaxialCTscanthroughthelowerchestshowingtheregionofthegastroesophageal
junction(arrow)atthelevelofthediaphragm(arrowhead)withaparaesophagealhernia
(asterisk).
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Bariumswallowinapatientwithaslidinghiatus
hernia

Abariumswallowshowsamoderatesizedslidinghiatushernia
(asterisk)abovethediaphragm(arrowhead),withwelldefinedgastric
folds(arrow).
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Bariumswallowofalargeparaesophagealhernia

Bariumswallowofaparaesophagealhernia.Notethatastheherniatedstomach
enlarges,itinvertsandtwistscausingavolvulus.Intheextreme,thisresultsinan
upsidedownstomach.Theesophagusisnotseeninthisimage,butifthe
gastroesophagealjunctionisatthelevelofthediaphragm,thiswouldbeatypeII
(paraesophageal)hernia.Morecommonly,itisabovethediaphragm,whichmakes
itatypeIII(paraesophageal)hernia.
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EndoscopicimageofatypeIslidinghiatushernia

Retroflexed(A)andforwardlooking(B)endoscopicviewsofasliding(typeI)
hiatushernia.Thesquamocolumnarjunction(SCJ)marksthedistallimitofthe
esophagealepithelium.DistaltotheSCJistheconstrictionofthe
diaphragmatichiatus.
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Subtypesofesophagogastricjunctionpressuremorphologyonesophagealpr

EGJmorphologysubtypes.Foreachpanel,theinstantaneousspatialpressurevariationplotcorrespondin
isillustratedbytheblacklinetotheright.Thespatialpressurevariationplotillustratesthepressurepro
intermediatevaluesbetweenthemeasuredvaluesthatoccurat1cmintervals.ThetwomainEGJcompo
independentlyquantifiedwhentheyaresuperimposedaswithatypeIEGJ(panelA).TheRIP,shownby
proximalmarginoftheEGJ.Duringinspiration(I)EGJpressureincreases,whereasitdecreasesduringex
TypeIIEGJpressuremorphologyisillustratedinpanelB.Notethetwopeaksontheinstantaneousspati
betweenthepeaksisgreaterthantheintragastricpressure.TheRIPisattheleveloftheCD.
PanelsCandDcorrespondtotypeIIIEGJpressuremorphology,definedasthepresenceoftwopeaksof
plotwiththenadirpressurebetweenthepeaksequaltoorlessthanintragastricpressure.TheRIPisatt
theleveloftheLESintypeIIIb(panelD).

EGJ:esophagogastricjunctions:secondsLES:loweresophagealsphincterCD:cruraldiaphragmE:expirationI:
From:KahrilasPJ,BredenoordAJ,FoxM,etal,andTheInternationalHighResolutionManometryWorkingGroup.Th
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disorders,v3.0.NeurogastroenterolMotil201527:160.http://onlinelibrary.wiley.com/doi/10.1111/nmo.12477/abs
ofJohnWiley&SonsInc.ThisimagehasbeenprovidedbyorisownedbyWiley.Furtherpermissionisneededbefore
oremailed.PleasecontactWiley'spermissionsdepartmenteitherviaemail:permissions@wiley.comorusetheRights
linkaccompanyingthisarticleonWileyOnlineLibrary(http://onlinelibrary.wiley.com).
Graphic86107Version3.0

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