Diaphragmatic hernia

Dr. Vu Thi Dinh

1. Imaging department reportImaging department report
Dr DinhDr Dinh

2. Nguyen Hong Linh , F, 19 Nguyen Hong Linh , F, 19
months, A16 months, A16
Dx: Dx: Sus Sus LungLung abscesabsces

7. DiagnosisDiagnosis
Hiatal hernia, Hiatal hernia, paraesophagealparaesophageal type type

8. Diaphragmatic herniaDiaphragmatic hernia

9. Diaphragmatic herniaDiaphragmatic hernia
Congenital: Congenital: two main types:two main types:
Bochdalek hernia : most common (75-90%), located posteriorly, Bochdalek hernia : most common (75-90%), located posteriorly,
presents earlierpresents earlier
Morgagni hernia : smaller, anterior and presents later Morgagni hernia : smaller, anterior and presents later
Congenital hiatus hernias may also occur, but are uncommon and Congenital hiatus hernias may also occur, but are uncommon and
distinct.distinct.
AcquiredAcquired
Traumatic diaphragmatic ruptureTraumatic diaphragmatic rupture
Hiatus herniaHiatus hernia
Iatrogenic

10. BochdalekBochdalek hernia hernia

11. 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

12. MorgagniMorgagni hernia hernia
Herniation through the Herniation through the foramen of foramen of MorgagniMorgagni which is which is
located immediately adjactent to the located immediately adjactent to the xiphodxiphod process process. .
The majority of hernias occur on the right side and are The majority of hernias occur on the right side and are
generally asymptomatic.generally asymptomatic.
As compared to the Bochdalek hernia, the Morgagni As compared to the Bochdalek hernia, the Morgagni
hernia is:hernia is:
-Rare -Rare
- Small - Small
-Anterior -Anterior
-At low risk of prolapse -At low risk of prolapse

14. 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

16. A 7-day-old boy with a
Morgagni hernia. a, b Anteroposterior
(a) and lateral (b) chest
radiographs show a poorly defined
right chest mass and right
upper lung atelectasis. c Sagittal
color Doppler sonogram of the
right chest obtained on the same
day shows herniation of the liver
(L) through an anterior foramen
of Morgagni hernia (arrows).
Note the abnormal course of the
hepatic 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 reconstructions
obtained the same day confirm
anterior liver (L) herniation

17. Hiatus hernia
A A hiatus herniahiatus hernia occurs where there is occurs where there is
herniation of 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 hernia (5%)- Rolling (para-oesophageal) hiatus hernia (5%)

20. Radiograph of a patient with a small axial hiatal hernia

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

22. 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

24. Sliding hiatus herniaSliding hiatus hernia
The The gastro-gastro-oesophagealoesophageal junction junction (GOJ) is usually (GOJ) is usually
displaced by more than 1cm above the hiatus. displaced by more than 1cm above the hiatus.
The oesophageal hiatus is often abnormally The oesophageal hiatus is often abnormally
widened to 3 - 4cm : the upper limit is 15mm. widened to 3 - 4cm : the upper limit is 15mm.
The gastric fundus may also be displaced above The gastric fundus may also be displaced above
the the diaphragmdiaphragm and present as a and present as a retrocardiacretrocardiac mass mass
on a chest radiograph. The presence of an air-on a chest radiograph. The presence of an air-
fluid level in the mass suggests the diagnosis. fluid level in the mass suggests the diagnosis.

25. Newborn with a congenital short esophagus presenting with
respiratory distress and gagging. a Chest radiograph shows a large
cystic structure in the right hemithorax within which is coiled a
nasogastric tube. Note a lens-shape density overlying the right lower
chest (arrows) b Radiograph obtained after administration of watersoluble
contrast material via the nasogastric tube confirms a short
esophagus with a fixed intrathoracic stomach. Note the malfixated
small bowel in the abdomen. c Sagittal T2-W MR image through the
right chest shows a small additional posterolateral (Bochdalek) hernia
with liver herniation (arrow)

27. A 2-year-old girl who
presented with intermittent abdominal
pain and mild shortness
of breath caused by a small
Bochdalek hernia. a Chest radiograph
shows a moderate left
plural effusion and mild small
bowel dilatation. b Close-up
image of the splenic flexure of
the colon obtained during an
enema using water-soluble contrast
material shows a complete
obstruction of the colon with a
beak-like appearance. At surgery,
ischemic colon was found
in the left chest incarcerated by
a 7-mm Bochdalek hernia

28. Rolling (para-oesophageal) hiatus Rolling (para-oesophageal) hiatus
herniahernia
The GOJ remains in its normal location while a The GOJ remains in its normal location while a
portion of the stomach herniates above the portion of the stomach herniates above the
diaphragm diaphragm

29. DiagnosisDiagnosis
UltrasoundUltrasound
Chest radiographChest radiograph
CTCT
MRIMRI

30. UltrasoundUltrasound
Sonographic findings includeSonographic findings include
cardiomediastinal shift + / - abnormal cardiac axis cardiomediastinal shift + / - abnormal cardiac axis
the stomach being at same transverse level as the heart : the stomach being at same transverse level as the heart :
this makes left sided hernias comparatively easier to this makes left sided hernias comparatively easier to
detect on ultrasound (as opposed to herniaion of detect on ultrasound (as opposed to herniaion of
echogenic liver on the right side) echogenic liver on 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

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

32. Chest radiograph Chest radiograph 
indistinct diaphragm with opacification of part indistinct diaphragm with opacification of part
of or all the hemithorax (typically left sided) of or all the hemithorax (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

33. Differential diagnosisDifferential diagnosis
congenital cystic adenomatoid malformation congenital cystic adenomatoid malformation
(CCAM) (CCAM)
retrocardiac lung abscess retrocardiac lung abscess
retrocardiac empyema retrocardiac empyema
Pulmonary sequestration Pulmonary sequestration
epiphrenic oesophageal diverticulum epiphrenic oesophageal diverticulum