Imaging department Imaging department

reportreport Dr DinhDr Dinh

Nguyen Hong Linh , F, 19 Nguyen Hong Linh , F, 19 months, A16 months, A16

Dx: Dx: Sus Sus LungLung abscesabsces

DiagnosisDiagnosis

Hiatal hernia, Hiatal hernia, paraesophagealparaesophageal type type

Diaphragmatic herniaDiaphragmatic hernia

Diaphragmatic herniaDiaphragmatic hernia

Congenital: Congenital: two main types:two main types:

Bochdalek hernia : most common (75-90%), located Bochdalek hernia : most common (75-90%), located posteriorly, presents earlierposteriorly, presents earlier

Morgagni hernia : smaller, anterior and presents Morgagni hernia : smaller, anterior and presents later later

Congenital hiatus hernias may also occur, but are Congenital hiatus hernias may also occur, but are uncommon and distinct.uncommon and distinct.

AcquiredAcquiredTraumatic diaphragmatic ruptureTraumatic diaphragmatic rupture Hiatus herniaHiatus herniaIatrogenic

BochdalekBochdalek hernia hernia

A 4-day-old infant with a Bochdalek defect and herniation of solid viscera presenting with mild respiratory distress. A Chest radiograph shows bowel in the left hemithorax and a softtissue retrocardiac mass (arrows). b Coronal reconstructed, contrast-enhanced CT image shows intrathoracic herniation of the spleen and left kidney through a large Bochdalek hernia

MorgagniMorgagni hernia hernia Herniation through the Herniation through the foramen of foramen of

MorgagniMorgagni which is located immediately which is located immediately adjactent to the adjactent to the xiphodxiphod process process. The . The majority of hernias occur on the right side majority of hernias occur on the right side and are generally asymptomatic.and are generally asymptomatic.

As compared to the Bochdalek hernia, the As compared to the Bochdalek hernia, the Morgagni hernia is:Morgagni hernia is:

-Rare -Rare - Small - Small -Anterior -Anterior -At low risk of prolapse -At low risk of prolapse

A 2-week-old boy with Morgagni defect presenting with respiratory difficulty. Anteroposterior (a) and lateral (b) chest radiographs show intrathoracic bowel herniating through an anterior foramen of Morgagnidefect

A 7-day-old boy with aMorgagni hernia. a, b Anteroposterior

(a) and lateral (b) chestradiographs show a poorly defined

right chest mass and rightupper lung atelectasis. c Sagittalcolor Doppler sonogram of the

right chest obtained on the sameday shows herniation of the liver(L) through an anterior foramen

of Morgagni hernia (arrows).Note the abnormal course of thehepatic vein and the difference

in echotexture of the intrathoracic(T) and intraabdominal (A)

portions of the liver. d, e Sagittal(d) and coronal (e) contrastenhanced

CT reconstructionsobtained the same day confirm

anterior liver (L) herniation

Hiatus hernia

A A hiatus herniahiatus hernia occurs where there occurs where there is herniation of is herniation of stomach stomach through the through the oesophagealoesophageal hiatus hiatus of the of the diaphragmdiaphragm

Sub types:Sub types:

- Sliding hiatus hernia (95%)- Sliding hiatus hernia (95%)

- Rolling (para-oesophageal) hiatus - Rolling (para-oesophageal) hiatus hernia (5%)hernia (5%)

Radiograph of a patient with a small axial hiatal hernia

A well-developed A ring is evident, A well-developed A ring is evident, but no B ring. In such cases the but no B ring. In such cases the criterion for defining hiatus hernia is criterion for defining hiatus hernia is the appearance of rugal folds the appearance of rugal folds traversing the diaphragmatic hiatus. traversing the diaphragmatic hiatus. The A ring has no anatomic correlate The A ring has no anatomic correlate but physiologically corresponds to but physiologically corresponds to the superior aspect of the lesthe superior aspect of the les

A 4-month-old girl with a paraesophageal hernia who presented with vomiting. A Chest radiograph obtained during an upper gastrointestinal series shows intrathoracic herniation and organoaxial volvulus of the stomach into a paraesophageal hernia. b Delayed radiograph of the upper abdomen shows herniation of the transverse colon

Sliding hiatus herniaSliding hiatus hernia

The The gastro-gastro-oesophagealoesophageal junction junction (GOJ) is (GOJ) is usually displaced by more than 1cm usually displaced by more than 1cm above the hiatus. The oesophageal hiatus above the hiatus. The oesophageal hiatus is often abnormally widened to 3 - 4cm : is often abnormally widened to 3 - 4cm : the upper limit is 15mm. the upper limit is 15mm.

The gastric fundus may also be displaced The gastric fundus may also be displaced above the above the diaphragmdiaphragm and present as a and present as a retrocardiacretrocardiac mass mass on a chest radiograph. on a chest radiograph. The presence of an air-fluid level in the The presence of an air-fluid level in the mass suggests the diagnosis. mass suggests the diagnosis.

Newborn with a congenital short esophagus presenting withrespiratory distress and gagging. a Chest radiograph shows a largecystic structure in the right hemithorax within which is coiled anasogastric tube. Note a lens-shape density overlying the right lowerchest (arrows) b Radiograph obtained after administration of watersolublecontrast material via the nasogastric tube confirms a shortesophagus with a fixed intrathoracic stomach. Note the malfixatedsmall bowel in the abdomen. c Sagittal T2-W MR image through theright chest shows a small additional posterolateral (Bochdalek) herniawith liver herniation (arrow)

A 2-year-old girl whopresented with intermittent abdominalpain and mild shortnessof breath caused by a smallBochdalek hernia. a Chest radiographshows a moderate leftplural effusion and mild smallbowel dilatation. b Close-upimage of the splenic flexure ofthe colon obtained during anenema using water-soluble contrastmaterial shows a completeobstruction of the colon with abeak-like appearance. At surgery,ischemic colon was foundin the left chest incarcerated bya 7-mm Bochdalek hernia

Rolling (para-oesophageal) Rolling (para-oesophageal) hiatus herniahiatus hernia

The GOJ remains in its normal The GOJ remains in its normal location while a portion of the location while a portion of the stomach herniates above the stomach herniates above the diaphragm diaphragm

DiagnosisDiagnosis

UltrasoundUltrasound Chest radiographChest radiograph CTCT MRIMRI

UltrasoundUltrasound

Sonographic findings includeSonographic findings include cardiomediastinal shift + / - abnormal cardiac cardiomediastinal shift + / - abnormal cardiac

axis axis the stomach being at same transverse level as the stomach being at same transverse level as

the heart : this makes left sided hernias the heart : this makes left sided hernias comparatively easier to detect on ultrasound comparatively easier to detect on ultrasound (as opposed to herniaion of echogenic liver on (as opposed to herniaion of echogenic liver on the right side) the right side)

portal veins in thorax (Doppler) portal veins in thorax (Doppler) absent bowel loops in the abdomen absent bowel loops in the abdomen there may be polyhydramnios as an ancilliary there may be polyhydramnios as an ancilliary

sonographic feature sonographic feature

US of chest-there are multiple fluid-filled loops of the bowel within the left hemithorax

Chest radiograph Chest radiograph 

indistinct diaphragm with opacification indistinct diaphragm with opacification of part of or all the hemithorax of part of or all the hemithorax (typically left sided) (typically left sided)

scaphoid abdomen scaphoid abdomen deviation of lines 3deviation of lines 3

endotracheal tube endotracheal tube nasogastic tube nasogastic tube umbilical arterial and venous catheters umbilical arterial and venous catheters

Differential diagnosisDifferential diagnosis

congenital cystic adenomatoid congenital cystic adenomatoid malformation (CCAM) malformation (CCAM)

retrocardiac lung abscess retrocardiac lung abscess retrocardiac empyema retrocardiac empyema Pulmonary sequestration Pulmonary sequestration epiphrenic oesophageal diverticulum epiphrenic oesophageal diverticulum