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Pictorial Essay
lntrathoracic Stomach Revisited
Suhny Abbara1.2, Mohammed M. H. Kalan3, Ann M. Lewicki 1

s urgical repair of paraesophageal

hernias, even when a large por­
tion of the stomach has herniated
intrathoracically, is now feasible using lap­
aroscopic techniques. Repair is possible with
portion of the stomach has herniated into
the chest (Fig. 2).

Type I Hiatal Hernia

ing to an intrathoracic stomach. The term
"parahiatal hernia" is reserved for rare cases
in which some fibers of the crura of the dia­
phragm are interposed between the esopha­
The type l hiatal hernia is also called the gus and the herniated stomach.
a low morbidity rate and good results, sliding or axial hernia; it is not considered
prompting some surgeons to advocate cor­ paraesophageal. This type of hernia repre­ Type 3 Hiatal Hernia
rective surgery electively in patients who sents 95% of all hiatal hernias. The esopha­ The type 3 hiatal hernia is called the
present with an intrathoracic stomach. Pre­ gogastric junction is displaced into the chest "mixed'. or "compound" hiatal hernia. This
operative imaging studies. which elucidate because of diffuse weakening and stretching type of hernia is the most common form of
the abnormal anatomy. can be of consider­ of the phrenicoesophageal membrane (Fig. paraesophageal hernias. combining the fea­
able help in planning the surgery. Radiolo­ I). The phrenicoesophageal membrane is
tures of the type 2 and the type I hernias. The
gists thus need to be familiar with the fonned by the fused layers of the endotho­ phrenicocsophageal membrane is weakened
anatomy and complications of a paraesoph­ racic fascia and the endoabdominal fascia, and stretched. The esophagogastric junction is
ageal hernia. Current textbooks of gas­ which cover both sides of the diaphragm. displaced into the chest. Additionally, a defect
trointestinal radiology cover this topic with The type l hiatal hernia may be associated is present in the anterolateral portion of this
little detail, and to our knowledge, this sub­ with incompetence of the distal esophageal membrane. Paraesophageal herniation is usu­
ject has not been addressed in recent publica­ sphincter, which can lead to the development ally large and is invariably associated with
tions in the radiology literature [1-3]. of gastroesophageal retlux disease. gastric rotation (Figs. I, 2, 5. and 6).
Classification of Hiatal Hernias Type 2 Hiatal Hernia
In the surgical literature, hiatal hernias The type 2 hiatal hernia is called the Type 4 Hiatal Hernia
are divided into three or four types (Fig. I). paraesophageal or rolling hernia. This type With marked widening of the diaphrag­
The intrathoracic stomach may be found in of hernia has a focal defect in the anterior matic hiatus. other organs such as the colon,
paraesophagcal hiatal hernias (types 2-4) and lateral aspect of the phrenicoesophageal omentum, small bowel. and liver can also
[4]. The paraesophageal hiatal hernia (types membrane. The gastric cardia and the esoph­ herniate into the chest (Figs. I and 7-9).
2-4) is an uncommon disorder, representing agogastric junction remain below the dia­ When that occurs. the hiatal hernia may be
approximately 5% of all hernias occurring phragm (Figs. l, 3, and 4). The fundus is classified as type 4 [4]. This classification is
through the esophageal hiatus. An intratho­ usually the lead point of the herniation not universally used. Some consider this
racic stomach results from a paraesoph­ through the diaphragmatic defect. The rest of merely a variation of advanced type 3 gas­
ageal hia1al hernia in which a substantial the stomach may then migrate upward, lead- tric herniation.
- ---------------
-
Received March 11, 2002; accepted after revision January 30, 2003.
1Department of Radiology, Georgetown University Medical Center, 3800 Reservoir Rd., N.W., Washington, DC 20007.
2Present address: Department of Radiology, CIMIT, Massachusetts General Hospital, Ste. 400, 100 Charles River Plaza, Boston, MA 02114. Address correspondence to S. Abbara.
3Department of Surgery, Georgetown University Medical Center, Washington, DC 20007.
AJR2003;181:403-414 0361--803X/03/1812-403©American Roentgen Ray Society

AJR:181, August 2003 403

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