Radiology of 

the Hiatal Hernia
19
Joseph Adam Sujka, Pete Peterson,
and Christopher DuCoin

Radiologic Classification 4 is a paraesophageal hernia that contains another

organ in addition to a hiatal hernia. Among the
Hiatal hernias are typically broken down into paraesophageal hernia types, Type 3 is the most
four subtypes, 1 through 4 [1]. Type 1 is also common making up 90% and Type 2 is the least
known as a sliding hiatal hernia. With this type, common [2] (Figs. 19.1 and 19.2).
the gastroesophageal junction migrates through There is a more nebulously defined type of
the diaphragm while the stomach stays in its nor- hiatal hernia, the “giant” paraesophageal hernia.
mal alignment with the fundus remaining below Some have advocated for giant hiatal hernias to
the gastroesophageal junction [2]. Greater than be defined as type 3 or 4 paraesophageal hernias.
95% of hiatal hernias are categorized as Type 1 While others suggest that the amount of stomach
and asymptomatic patients do not require repair contained in the chest, half the stomach or more,
as long-term studies have shown a lack of need be used to define this type of hiatal hernia [8–10].
for emergent repair [3, 4]. Type 2–4 hiatal hernias It is the opinion of the authors that a giant hiatal
are referred to as paraesophageal hernias because hernia is simply a large paraesophageal hernia
unlike Type 1 hernias, the posterolateral phreno- requiring more mediastinal dissection than typi-
esophageal ligament is preserved around the gas- cally required for hiatal hernia repair. An addi-
troesophageal junction [5]. tional type of hiatal hernia to consider is a hiatal
Type 2 paraesophageal hernias have the gastro- hernia recurrence. Defining a recurrence begins
esophageal junction in the normal anatomic posi- with radiologic proof. However, clinical symp-
tion however a portion of fundus herniates toms may not always accompany radiologic find-
adjacent to the esophagus into the thorax. Type 3 ings [11–13]. While there is no strict definition of
paraesophageal hernias are a combination of Type what constitutes a radiologic recurrence some
1 and 2 with both the fundus and gastroesopha- define a radiologic recurrence only when the
geal junction herniating through the hiatus. Type recurrence is 2 cm in length [14]. Incidental dis-
covery of a hiatal hernia recurrence and the reop-
eration should be balanced against the symptoms
J. A. Sujka (*)
GI Surgery, University of South Florida, of the patient as most recurrences are small and
Tampa, FL, USA asymptomatic [15]. Recurrence should be treated
e-mail: [email protected] similarly to a newly diagnosed hiatal hernia with
P. Peterson · C. DuCoin a thorough history and physical, imaging, and
Department of Surgery, University of South Florida at strict definition of the patient’s symptoms.
Tampa General Hospital, Tampa, FL, USA
e-mail: [email protected]; [email protected]

© Springer Nature Switzerland AG 2023 225

S. Docimo Jr. et al. (eds.), Fundamentals of Hernia Radiology,
https://doi.org/10.1007/978-3-031-21336-6_19
226 J. A. Sujka et al.

Fig. 19.1  Types of paraesophageal hernias. Modified from [6]

19  Radiology of the Hiatal Hernia 227

Fig. 19.2  Radiologic images for hiatal hernia types. Modified from [6, 7]

The final radiologic finding to take note of greater curve [3]. With complete gastric obstruc-
relating to a hiatal hernia is gastric volvulus. tion, the patient may present with Borchardt’s
Gastric volvulus can occur in either the chest or triad—severe epigastric pain, unproductive retch-
the abdomen and is defined based on the axis of ing, and the inability to pass a nasogastric tube
rotation. The two types of rotation are organoax- [16]. Complete obstruction from gastric volvulus
ial and mesenteroaxial, with organoaxial being is a surgical emergency requiring operative
the more common of the two. Organoaxial rota- exploration to avoid gastric ischemia or necrosis.
tion is when the stomach rotates on its longitudi- However, patients with large hiatal hernias may
nal axis, from cardia to pylorus, where present with incomplete obstruction from gastric
mesenteroaxial volvulus is when the stomach volvulus and can be more completely worked up
rotates around its transverse axis, from lesser to prior to operative intervention (Fig. 19.3).
228 J. A. Sujka et al.

a b

Fig. 19.3  Gastric volvulus: (a) Organoaxial, (b) Mesenteroaxial. Modified from [6, 17]
19  Radiology of the Hiatal Hernia 229

Diagnostic Workup the size, contents, and functional difficulties

and Preoperative Imaging these hernias represent (Fig. 19.4).
The next type of study that can be utilized is a
The diagnosis of a hiatal hernia can be completed contrasted study such as an upper gastrointestinal
through various radiologic tests. Once the diag- series (UGI). This test is useful for gauging the
nosis of a hiatal hernia has been completed no size of the hiatal hernia and localizing the gastro-
further testing is required for operative repair if esophageal junction. It can also suggest dys-
the patient is symptomatic. Broadly speaking all motility of the esophagus that would benefit from
patients should undergo esophagogastrodoude- high-resolution manometry (HRM). An UGI can
noscopy (EGD) followed by pH testing if Los also increase suspicion for a short esophagus
Angeles (LA) grade C or D esophagitis is not which may require esophageal lengthening pro-
seen. Next, an upper gastrointestinal series (UGI) cedures such as a Collis gastroplasty [20]. Finally,
is performed to evaluate the size, motility, and these dynamic studies give information on the
emptying of the hernia. If there is any concern for transit of contrast into and out of the herniated
dysmotility high-resolution manometry should stomach and can be particularly useful when try-
also be used. ing to determine if a patient has complete gastric
One of the first tests that can be utilized is a outlet obstruction. When performing an UGI
plain chest radiograph. Characteristic findings of barium should be used due to the risk of aspira-
a hiatal hernia include retrocardiac air-fluid lev- tion that can occur with larger partially obstructed
els, visceral gas in the mediastinum, loops of hernias. If ionic water-soluble contrast, such as
bowel running vertically towards the chest, and gastrografin, is used and aspirated it can lead to
an upward displacement of the transverse colon if chemical pneumonitis in the lungs [21].
it is involved in the hernia [18]. While plain chest UGI can also be used to calculate the cross-­
radiographs may suggest the presence of a hiatal sectional area of the herniated intrathoracic stom-
hernia other studies are better able to characterize ach as well as the hiatal surface area [22, 23].

Fig. 19.4  Plain chest radiograph with hiatal hernia. Open access from [19]
230 J. A. Sujka et al.

However, the utility of this additional informa- Intraoperative Testing

tion appears to be limited at this time. One study
by Swanstrom et al. examined 100 patients with Some centers utilize High-Resolution Manometry
chronic gastroesophageal reflux disease (GERD) (HRM) prior to hiatal hernia repair. This is to
who were planned for laparoscopic fundoplica- characterize the contractility function of the
tion. Prior to operative intervention, the patients esophagus as well as visualize a hiatal hernia.
underwent barium study to measure the presence However, due to the configuration of the stomach
of a hiatal hernia and they concluded that barium it is sometimes impossible to cannulate the GEJ
swallow had no correlation with hiatal surface and some have begun to evaluate intraoperative
area or hiatal hernia size for all patients [24]. tools for use during hiatal hernia repair [29].
Another study by Aye et al. looked at diaphrag- Impedance planimetry, or Endoluminal func-
matic tension radiologically and then intraopera- tional lumen imaging probe (EndoFLIP), is a
tively to determine shapes of diaphragmatic relatively new technology which can be used
hernias and their associated tension. Again, there intraoperatively to evaluate the distensibility of
was a limited correlation between the width of the esophagus. This information may be used to
the hiatal opening and associated tension [25]. characterize the esophagus both before and after
These limitations of UGI series may be due to repair with hopes of improving outcomes by indi-
their two-dimensional perspective but is more vidualizing operative repair based on intraopera-
likely due to the complexity of the diaphragmatic tive testing.
hiatus and its mobility which makes quantifica- The specifics of the function of EndoFLIP
tion and characterization difficult. may be found elsewhere, but briefly this modality
Computed Tomography (CT) can be useful in introduces a balloon catheter into the esophagus,
the acute setting to determine complications either 8 cm or 16 cm, then inflates to a fill volume
related to a hiatal hernia but also in quantifying of 30 or 40  mL, and measure pressure in a
the size and complexity of a hiatal hernia. Unlike 360-degree fashion along the catheter. In the
plain chest radiographs and UGI, a CT scan can operating room, the catheter used is 8 cm as the
clearly visualize the thoracic cavity and the hiatal area being measured is just the GEJ. Measurements
hernia contents. Multi-slice CT scans with coro- are recommended to be taken after crural dissec-
nal, sagittal, and 3D reformatted images have tion and hernia reduction, after crural closure,
been shown to increase the sensitivity of CT and after fundoplication/magnetic sphincter aug-
scans for diagnosis of hiatal hernias [26]. The mentation. This provides multiple time points to
larger the hernia the more useful a CT scan will evaluate the changes to the esophagus and disten-
be in the preoperative setting but in smaller and sibility at each step of operative repair. Target
less complex hernias an UGI may be sufficient. distensibility index (DI) is the value targeted by
Generally, with Type 3 or 4 paraesophageal her- surgeons when evaluating their repair. This value
nias, or redo foregut surgery, a CT scan should be represents the change in esophageal compliance.
performed prior to operative intervention. The DI can be measured both with or without
Other types of imaging studies have been per- pneumoperitoneum in the abdomen. Without
formed for diagnosis of a hiatal hernia such as pneumoperitoneum present, the DI should be
nuclear medicine studies [27], transesophageal between 2.0 and 3.5 mm2/mmHg and with pneu-
echocardiogram [28], and endoscopic ultrasound; moperitoneum should be >0.5  mm2/mmHg [30,
however, in the practical setting these modalities 31]. Other values that can be utilized by the sur-
do not have a routine place in the diagnosis or geon include maximum diameter (Dmin) and
management of hiatal hernias. In most hiatal her- cross-sectional area (CSA). One study demon-
nias upper endoscopy and a contrast study will be strated a decrease of Dmin  ≤  0.15  mm or a
sufficient testing prior to operative intervention. decrease in CSA ≤ 1.5 mm2 resulted in persistent
19  Radiology of the Hiatal Hernia 231

Fig. 19.5  Example of intraoperative EndoFLIP values. Modified from [30]

heartburn symptoms [32]. How all these values tion leading to ischemia and subsequent
correlate with both short- and long-term out- ­perforation. Elderly patients and those with ath-
comes is still an area of active research but it is erosclerotic disease are at the highest risk of isch-
possible that EndoFLIP may become a routinely emia and perforation if wrap herniation occurs
used adjunct in the operating room for surgeons [33]. The incidence of wrap migration is 7–20%
repairing hiatal hernias (Fig. 19.5). in the literature [34, 35]. Chest x-ray, UGI, and
CT scan can be used to evaluate patients with
findings of retrocardiac gas-filled structure with
Postoperative Imaging defined edges in continuity with the stomach
and Perioperative Findings being seen [36]. Patient with more chronic reher-
niation of the fundoplication leads to postopera-
Imaging after hiatal hernia repair varies by pro- tive failure including chronic postoperative reflux
vider. Some believe in routine postoperative with or without dysphagia (Fig. 19.6).
imaging as a means of documenting the repair of In patients with immediate postoperative dys-
the hiatal hernia and ruling out immediate com- phagia, an UGI is helpful to determine the sever-
plications. Others will selectively utilize imaging ity of any postoperative stenosis. Some
in patients with a difficult intraoperative dissec- postoperative dysphagia can be secondary to
tion or a patient undergoing revisional surgery. operative intervention and swelling but can also
While still others feel that symptoms should be secondary to an overly tight fundoplication or
guide immediate postoperative imaging. The crural repair. Intolerance to saliva or liquids is
SAGES Guidelines for the management of hiatal concerning for dysphagia that will require inter-
hernia state that “routine postoperative contrast vention. Findings consistent with dysphagia that
studies are not necessary in asymptomatic may not resolve with conservative management
patients,” citing a strong level of evidence [3]. If include contrast stasis with no transit into the
patients are symptomatic then UGI and CT scans stomach and esophageal dilation. Some surgeons
are useful in ruling out key postoperative compli- are utilizing EndoFLIP intraoperatively as a
cations. These postoperative complications means of avoiding postoperative dysphagia [37].
include immediate postoperative recurrence, With the size of some hernias, an extensive
severe dysphagia, pneumothorax, and esopha- mediastinal dissection is sometimes required. As
geal/gastric leak. a result, patients may develop pneumothorax,
Immediate postoperative recurrence can lead mediastinal air, and even mediastinal abscesses.
to transdiaphragmatic herniation of a fundoplica- Patients with pneumothorax will present with
232 J. A. Sujka et al.

Smaller asymptomatic pneumothoraces do not

require intervention if incidentally discovered on
imaging for other reasons. In the setting of medi-
astinal air, consideration must be given to a pos-
sible leak even though pneumomediastinum may
be normal in the immediate postoperative period.
The same can be said of mediastinal fluid but this
is more concerning for a mediastinal abscess or
leak. UGI or CT scan with oral contrast can be
used to further evaluate the mediastinum.
Findings of air-fluid levels in the chest or a large
contained fluid collection is concerning for a
mediastinal abscess [33] (Fig. 19.7).
One of the most dreaded postoperative com-
plications is an esophageal leak which can pres-
ent on a spectrum. Presentations vary from
tachycardia without any additional findings to a
more pronounced presentation with high fevers,
hypotension, and sepsis. UGI or CT scans with
oral contrast are effective first-line tests to evalu-
ate for a leak. Differentiation should be made
between a pseudoleak, contained leak, and free
perforation. A pseudoleak is not a true leak and
will not present with sepsis or hemodynamic
instability. It is seen on CT scan as a smooth vari-
able defect in the region of the gastric fundus
with a variable degree of edema at the GEJ.  A
contained or small leak will show up as linear
tracks of contrast extending from the wrap. The
most common position is in the posterior inferior
border. Larger or free leaks will show up as large
Fig. 19.6  Plain chest X-ray, UGI, and CT scans consis- collections of contrast with adjacent inflamma-
tent with herniated nissen fundoplication. Creative
Commons [36]
tory changes [33]. If there is any question of the
location or severity of the leak and the patient is
stable they can be taken for fluoroscopy to evalu-
hypoxia and possibly findings of tension physiol- ate the leak in real time [38]. Typically, patients
ogy. These patients are treated with either a pig- should undergo emergent surgical repair with any
tail catheter or chest tube if clinically necessary. suspicion of a leak [39] (Fig. 19.8).
19  Radiology of the Hiatal Hernia 233

a b

c d

Fig. 19.7  CT scans with findings consistent with a mediastinum (d) contrast leakage into the mediastinum.
mediastinal abscess (a and b) periesophageal fluid collec- With permission from [33]
tion in the mediastinum (c) contrast leakage into the

a b

Fig. 19.8  Leak after nissen with Type 3 giant hiatal her- example of extraluminal fluid with air contrast levels, and
nia repair, (a) shows a large irregular extraluminal collec- (d) shows a drain in position. With permission from [33]
tion, (b) contrast in the right paracolic gutter, (c) is an
234 J. A. Sujka et al.

c d

Fig. 19.8 (continued)

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