This is a Chest Xray Of a 55 year old male who came to a gastroenterologist, complaining of burning of pain in the epigastric region , usually getting  after meals and was made worse by stooping or lying down.He has got Omeprazole  from a general Practitioner for several times but his symptom  was not settled fully.What is the abnormality seen in this Xray? 

 

 ANSWER - SLIDING HIATUS HERNIA
 
The Commonest type of hiatus hernia where the gastroesophageal junction moves above the diaphragm together with some of the stomach.It  results a symmetrical, bell-like dilatation of part of the stomach within the thoracic cavity.

Causes
  • Congenital: short oesophagus
  • Increased abdominal pressure
  • Decreased elasticity of the  crus
  • Muscular degeneration of the gastric fundus & lower oesophagus
  • Oesophageal spasm and fibrosis from reflux

A sliding hiatus hernia is of no significance unless accompanied by abnormal gastro-oesophageal reflux.

CLINICAL FEATURES
More common in females(4:1)
Age group >40 years
Many are asymptomatic
  1. Reflux oesophagitis - heartburn
  2. Dysphagia
  3. Waterbrash
  4. Regurgitation of food at night

Differential diagnosis
Achalasia
Peptic ulcer

Complications

  1. Oesophagitis and progressive fibrosis of the wall may lead to stricture
  2. Barret's oesophagus
  3. Aspirational pneumonia
  4. Gastric volvulus
  5. If chronic bleeding leading to anaemia

MANAGEMENT
Life Style changes
 Avoid eating  just before bedtime
 Eat frequent small meals
 Elevate the head end of the bed
 Stop smoking
Drug management - proton pump inhibitors
Surgery - laparoscopic funoplication (partial or total wrapping of the fundus of the stomach around the lower oesophagus)

Prognosis
Very good following the surgery

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17 comments

  1. Anonymous Says:
  2. GERD

     
  3. Anonymous Says:
  4. GERD,Barrett's esophagus

     
  5. Anonymous Says:
  6. hiatus hernia. gastric bubble seen in the mediastnium.

     
  7. Anonymous Says:
  8. most propalpy haiatus hernia

     
  9. Anonymous Says:
  10. GERD,barret's esophagus

     
  11. Anonymous Says:
  12. hiatus hernia

     
  13. Anonymous Says:
  14. are there any answers too for all these xrays? thanks!

     
  15. Anonymous Says:
  16. hiatus hernia because of the gastric bubble superimposed on the heart's image and the sinuous, full of air image of the esophagus.but what's with the huge distance between the clavicles and the top of his lungs, and the hypertransparency of the lungs?does he also have emphysema?

     
  17. dr.butterfly Says:
  18. it is most likely hiatus hernia.
    looking at his lungs, could he have emphysema~?

     
  19. dr.butterfly Says:
  20. when and how can we be sure of our answers?

     
  21. Anonymous Says:
  22. I put the answer for this case on 2mrw.....

     
  23. Anonymous Says:
  24. is there any air fluid level over heart shadow?

     
  25. Anonymous Says:
  26. hiatus hernia the shadow is seen in front of the heart and this shadow also contains gas confirming its not heart

     
  27. tariq ali Says:
  28. This comment has been removed by the author.  
  29. tariq ali Says:
  30. expanded lung with mediastinal widening and fibrotic changes in lower lung fields, could have sarcoid lung disease/conective tissue disorder adding to GERD? couldnt appreciate any hiatal herniation sign though.neck soft tissue shadow is fishy as well with thoracic tracheal deviation to right side? clinical relevance is important.may need a ct scan if increased clinical suspicion?

     
  31. Anonymous Says:
  32. thanks for displaying correct answers
    arash from iran

     
  33. Anonymous Says:
  34. hiatus hernia

     

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