Roentgen Findings in Obstructed Diaphragmatic Hernia

Abstract

As one reviews the rather extensive literature concerned with obstructed diaphragmatic hernia, it becomes evident that there has been considerable difficulty in making this diagnosis. Yet our own experience indicates that it can be promptly established roentgenologically if certain basic facts and principles are kept in mind. The importance of early recognition of this condition cannot be overemphasized, since strangulation and other serious sequelae so often supervene that in untreated cases the mortality approaches 90 per cent (19). Obstruction may complicate any type of diaphragmatic hernia (3, 20). It is relatively rare, however, in right-sided traumatic hernia since the liver generally prevents the gut from entering the chest (14). The present discussion will be limited to hiatal and traumatic hernia of the left hemi-diaphragm, the two most common types, but the roentgen signs to be described are applicable as well to hernias through the other orifices. Obstructed diaphragmatic hernia is not rare. Surprisingly, in collected series, 80 to 90 per cent are of the traumatic variety and only 10 to 20 per cent are hiatal (4). Our personal experience is based on 9 cases of hiatal hernia and approximately 25 cases of traumatic hernia seen over a period of about fifteen years at the University of Cincinnati Medical Center. Obstructed Hiatal Hernia In hiatal hernia the obstruction is generally a complication of a large sliding hernia with an esophagus of normal overall length that enters the stomach above the diaphragm. The obstruction, which is complete or nearly so, almost always appears to be the direct result of an acute volvulus of the stomach (5, 13, 16). The volvulus in this instance is a true twist of 180° or more on the long (cardiopyloric) axis of the stomach; it is not merely the partial torsion or inversion so commonly seen in uncomplicated hiatal hernia (1, 15). In the great majority of unobstructed hiatal hernias the fundus, at least, lies above the diaphragm. On occasion, only the distal stomach is herniated (9). In 7 of our cases an upper gastrointestinal series was available during a relatively asymptomatic period. In each instance the esophagogastric junction, the fundus, and a variable segment of the body of the stomach were in the thorax (Figs. 2, B, 3, C, 4, A). When obstruction supervened, this preexisting relationship was reversed in all but one case, so that the distal stomach replaced the proximal segment within the hernia, and the esophagus entered the stomach below the diaphragm (Figs. 3, A, 4, B). This interesting reversal of position was also noted by Pineau-Valencienne (16) and by Patel et al. (13). It occurs in most instances of hiatal hernia with volvulus, although few case reports mention or illustrate this point. Volvulus is not the only cause of obstruction in hiatal hernia (10).