The difference in clinical and barium radiographic findings for patients with large hiatal hernias and a floppy fundus with those patients with large… [601873]

1Ministery of Health of the Republic of Moldova State University of Medicine and Pharmacy “N. Testemitanu” Department of Radiology and Medical Imaging DIPLOMA THESIS Radiological and Imagistic diagnosis of Hiatus Hernia Name of the student: [anonimizat] , group VI, gr. M1053 Scientifical coordinator Andrei Cealan asistent universitar Chisinau 2016

2STATEMENT I hereby declare that the license thesis titled: “Radiological and Imagistic diagnosis of Hiatus Hernia” Is written by me and has never been submitted to another university or institution of higher education in the country or abroad. Also, that all sources used, including those on the Internet, are given in the paper with the rules for avoiding plagiarism: -all the fragments of text reproduced exactly, even in his own translation from another language are written between quotation marks and have a detailed reference source; -Reformulation of the texts in own words written by other authors have detailed reference; -summarizing the ideas of other authors have detailed reference to the original text.
Date: 10.01.2016 Zaid Abed El Fatah

3ABBREVIATIONS 1.EGJ Esophago-Gastric junction 2.Anti-CCP Antibodies to cyclic citrullinated peptides 3.BME Bone marrow edema 4.DIP Distal interphalangeal joint 5.DMARDS Disease-modifying antirheumatic drugs 6.ERA Early rheumatoid arthritis 7.ESTRA Established rheumatoid arthritis 8.EULAR European league against rheumatisim 9.FOV Field of view/vision 10.GM-CSF Granulocyte-macrophage colony-stimulating factor 11.IP Interphalangeal joint 12.MCP Metacarpophalangeal joint 13.MRI Magnetic resonance imaging 14.MTP Metatarsophalangeal joint 15.OMERACT Outcome measurement of rheumatoid arthritis clinical trials 16.PIP Proximal interphalangeal joint 17.RA Rheumatoid Arthritis 18.RAMRIS Rheumatoid Arthritis MRI scoring System 19.RCC Radiocubitocarpal joint 20.RF Rheumatoid Factor

421.RF Radio-Frequency 22.STRI Short inversion time inversion recovery 23.TLRs Toll-like receptors 24.VERA Very early Rheumatoid Arthritis

5CONTENTS CHAPTER I – PREFACE 5 ……………………………………………………………………………..1.Actuality and the research level of the investigated theme… 5 ……………….2.The aim and the objectives of the thesis 5 …………………………………………….3.The scientific news of the obtained results 6 …………………………………………CHAPTER II – BIBLIOGRAPHIC ANALYSIS… 7 ……………………………………..1.Rheumatoid Arthritis Disease 7 ………………………………………………………..2.Epidemiology 7 ………………………………………………………………………………..3.Clinical features of rheumatoid arthritis disease. 8 …………………………….4.Pathology 10 …………………………………………………………………………………….5.Morphology 12 …………………………………………………………………………………6.Pathogenesis 13 ………………………………………………………………………………..7.Joint involvement in RA 15 ……………………………………………………………..8.Diagnostic Methods 17 ……………………………………………………………………9.Magnetic Resonance Imaging Technique… 19 ……………………………………..CHAPTER III –MATERIAL AND RESEARCH METHODS… 23 ………………….CHAPTER IV –PERSONAL RESULTS AND DISCUSSION 27 ……………………CHAPTER V – CONCLUSION 34 …………………………………………………………….BIBLIOGRAPHY 35 ………………………………………………………………………………………

6CHAPTER I – PREFACE 1.Actuality, and the research level of the investigated theme Hiatus hernia refers to conditions in which elements of the abdominal cavity, most commonly the stomach, herniate through the esophageal hiatus into the mediastinum. With the most common type (type I or sliding hiatus hernia) this is associated with laxity of the phrenoesophageal membrane and the gastric cardia herniates. Sliding hiatus hernia is readily diagnosed by barium swallow radiography, endoscopy, or manometry when greater than 2 cm in axial span. However, the mobility of the esophagogastric junction precludes the reliable detection of more subtle disruption by endoscopy or radiography. Detecting lesser degrees of axial separation between the lower esophageal sphincter and crural diaphragm can only be reliably accomplished with high resolution manometry, a technique that permits real time localization of these esophagogastric junction components without swallow or distention related artifact. The radiographic demonstration of a sliding hiatus hernia is usually done in the setting of a barium swallow examination. However, in order to demonstrate the relative positions of the EGJ and the diaphragmatic hiatus, the positions of these structures must be visible radiograpically, which means the esophagus must be distended with consequent shortening and displacement of the EGJ as discussed above. Recognition of this confounding effect led to the 2 cm rule wherein there must be more than 2 cm separation between the B ring and the diaphragmatic hiatus before being considered a sliding hiatus hernia.

72.The aims and objectives of the thesis The intentions and the aim of this work is to carry out the importance of the radiological and imaging in the assessment of Hiatus Hernia; due to its capacity to help identify the key pathologic features of this disease at presentation, showing how the radiographic and imagestic images has demonstrated good sensitivity for the detection and the upward sliding of the LES and stomach cardia which are considered the main radiological findings on which the diagnosis of hiatus hernia is based on. Objectives 1.To see what are the most important early changes observed in patient with hiatus hernia. 2.To see which are the most commonly involved types of hiatus hernia 3.To see which is the best radiological and imagistic method use in the diagnosis of hiatus hernia. 4.To see what is the most dominating early change that involves all patients in early stages of hiatus hernia. 3.The scientific news of the obtained results Over the last years longitudinal studies have demonstrated that barium swallowing radiography has enormous potential as an outcome measure in hiatus hernia. barium swallowing provides a remarkable sensitivity in detecting the pathologic changes characterestic for hiatus hernia such as the upward sliding of the LES. chest radiograph may reveal a large hiatal hernia, and many incidentally diagnosed hiatal hernias are discovered in this manner, a barium study of the esophagus helps establish the diagnosis with greater accuracy

8CHAPTER II – BIBLIOGRAPGIC ANALYSIS 1.Hiatus Hernia The esophageal hiatal orifice is an elliptically shaped opening through the diaphragm with its long axis in the sagittal plane through which the esophagus and vagus nerves gain access to the abdomen. In general terms, hiatus hernia refers to herniation of elements of the abdominal cavity through the esophageal hiatus of the diaphragm and into the mediastinum. Of the openings through the diaphragm, it is only the esophageal hiatus that is vulnerable to visceral herniation because it faces directly into the abdominal cavity and, hence, is directly subjected to the pressure stresses between the two cavities. Notably, the esophagus does not tightly fill the hiatus because it needs to expand to accommodate luminal contents. Thus, the integrity of the hiatus depends upon the structures bridging the gap between the esophagus and the surrounding crural diaphragm making the detailed anatomy of this area of prime importance. 2.Anatomy of the Hiatus and Gastroesophageal Junction Although there is some anatomic variability, the most common anatomic pattern is for the hiatus to be formed by elements of the right diaphragmatic crus [1]. The crura arise from tendinous fibers emerging from the anterior longitudinal ligament over the upper lumbar vertebrae (Figure 1). The crura pass upward in close contact with the vertebral bodies for most of their course and incline forward only as they arch around the esophagus [1]. Upon emerging from the tendinous origin of the right crus, the muscle fibers form two ribbon-like bundles separated by connective tissue. The dorsal bundle forms the left limb of the right crus (thoracic aspect) and the ventral bundle becomes the right limb (abdominal aspect) of the right crus. As they approach the hiatus, the muscle fibers diverge and cross each other in a scissor-like fashion with the ventral bundle passing to the upper right region and the dorsal bundle passing to the upper left region. The lateral fibers of each hiatal limb insert directly into the central tendon of

9the diaphragm but the medial fibers, which form the hiatal margins, incline toward the midline and decussate with each other in a trellis-like fashion in front of the esophagus. Fig. 1 The most common anatomy of the diaphragmatic hiatus in which the muscular elements of the crural diaphragm derive from the right diaphragmatic crus. The right crus arises from the anterior longitudinal ligament overlying the lumbar vertebrae. Under normal circumstances, the esophagus is anchored to the diaphragm such that the stomach cannot be displaced through the hiatus into the mediastinum. The main restraining structures are the phrenoesophageal ligaments, alternatively referred to as the phrenoesophageal membrane, and an aggregation of posterior structures including the vagus nerve and radicles of the left gastric vein and artery [2, 3]. The phrenoesophageal membrane is formed from the fascia transversalis on the under surface of the diaphragm and, to a lesser degree, fused elements of the endothoracic fascia. This elastic membrane inserts circumferentially into the esophageal musculature, close to the squamocolumnar junction, and extends for about a centimeter above the gastroesophageal junction [5]. Thus, the axial position of the squamocolumnar junction is normally within or slightly distal to the diaphragmatic hiatus and surrounded by the crural diaphragm [6]. In addition to its role of maintaining fixation of the esophagogastric region to the diaphragm, the phrenoesophageal membrane also closes the potential space between the esophagus and the diaphragm making it a key structure to consider in the pathogenesis of hiatus hernia. With age, the amount of elastic tissue in the phrenoesophageal membrane progressively declines, increasing its laxity and increasing the risk for developing hiatal hernias [7].

103.Epidemiology Incidence of hiatal hernias increases with age; approximately 60% of individuals aged 50 or older have a hiatal hernia. Of these, 9% are symptomatic, depending on the competence of the lower esophageal sphincter (LES). 95% of these are "sliding" hiatus hernias, in which the LES protrudes above the diaphragm along with the stomach, and only 5% are the "rolling" type (paraesophageal), in which the LES remains stationary but the stomach protrudes above the diaphragm. People of all ages can get this condition, but it is more common in older people. According to Dr. Denis Burkitt, "Hiatus hernia has its maximum prevalence in economically developed communities in North America and Western Europe … In contrast the disease is rare in situations typified by rural African communities. 4.Clinical features of Hiatus Hernia Hiatal hernias are relatively common and, in themselves, do not cause symptoms. For this reason, most people with hiatal hernias are asymptomatic. Hiatal hernias may predispose to reflux or worsen existing reflux in a minority of individuals. Physicians should resist the temptation to label hiatal hernia as a disease.Patients can have reflux without a demonstrable hiatal hernia. When a hernia is present in a patient with symptomatic GERD, the hernia may worsen symptoms for several reasons, including the hiatal hernia acting as a fluid trap for gastric reflux and increasing the acid contact time in the esophagus. In addition, with a hiatal hernia, episodes of transient relaxation of the LES are more frequent and the length of the high-pressure zone is reduced. The main symptoms of a sliding hiatal hernia are those associated with reflux and its complications. No clear correlation exists between the size of a hiatal hernia and the severity of the symptoms. A very large hiatal hernia may be present with no symptoms at all. Some complications are specific for a hiatal hernia. Esophageal complications: •By far, the majority of hiatal hernias are asymptomatic. •Often, patients are left with the impression that they have a disease when a hiatal hernia is diagnosed. •In rare cases, however, a hiatal hernia may be responsible for intermittent bleeding from associated esophagitis, erosions (Cameron ulcers), or a discrete

11esophageal ulcer, leading to iron-deficiency anemia. The prevalence of large hiatal hernias in patients with iron deficiency anemia is 6-7%. This particular complication is more likely in patients who are bed-bound or those who take nonsteroidal anti-inflammatory drugs. Massive bleeding is rare. Nonesophageal complications: •Incarceration of a hiatal hernia is rare and is observed only with paraesophageal hernia. •When this occurs, it can present abruptly, with a sudden onset of vomiting and pain, sometimes requiring immediate operative intervention. 4.Types of hiatal hernia With hiatus hernia elements of the abdominal cavity, most commonly the stomach, are displaced through the esophageal hiatus of the diaphragm into the mediastinum. The most comprehensive classification scheme recognizes 4 types of hiatal hernia. With type I, or sliding hiatal hernia, there is a widening of the muscular hiatal tunnel and circumferential laxity of the phrenoesophageal membrane, allowing a portion of the gastric cardia to herniate upward (Figure 2). With a well developed hernia, the esophageal hiatus abuts directly on the transverse membrane of the central tendon of the diaphragm and the anterior hiatal muscles are absent or reduced to a few atrophic strands [1]. The hiatus itself is no longer a sagittal slit but a rounded opening whose transverse diameter approximates the sagittal diameter in size. This change in caliber of the hiatus is most apparent during distention [8]. Associated with the widening of the hiatal orifice, the phrenoesophageal membrane becomes attenuated and inconspicuous in comparison to its normal prominence. However, although thinned, the phrenoesophageal membrane remains intact and the associated herniated gastric cardia is contained within the posterior mediastinum. Type I hiatus hernias are by far the most common type. The major significance of type I hernias is in their association with reflux disease. They are also the most difficult to objectively define and, hence, the major focus of controversy in diagnosis.

12Figure 2 Distinction between a sliding hiatal hernia (type I) and paraesophageal hernia (type II). With type I hernia the leading edge is the gastric cardia while with type two it is the gastric fundus. The SCJ maintains its native position in the paraesophageal … The less common types of hiatus hernia, Types II, III and IV are all varieties of “paraesophageal hernias.” Taken together, these account for, at most, 5–15% of all hiatal hernias [9]. Although these hernias may also be associated with significant gastroesophageal reflux their main clinical significance lies in the potential for mechanical complications. A type II hernia results from a localized defect in the phrenoesophageal membrane while the gastroesophageal junction remains fixed to the preaortic fascia and the median arcuate ligament (Figure 2) [9]. The gastric fundus then serves as the leading point of herniation. Type III hernias have elements of both types I and II hernias. With progressive enlargement of the hernia through the hiatus, the phrenoesophageal membrane stretches, displacing the gastroesophageal junction above the diaphragm, thereby adding a sliding element to the type II hernia. Type IV hiatus hernia is associated with a large defect in the phrenoesophageal membrane, allowing other organs, such as colon, spleen, pancreas and small intestine to enter the hernia sac. Although the etiology of paraesophageal hernias is usually unclear, they are a recognized complication of surgical dissection of the hiatus as occurs during antireflux procedures, esophagomyotomy, or partial gastrectomy. Many patients with a type II hernia are either asymptomatic or have only vague, intermittent symptoms. When present, symptoms are generally related to ischemia or either partial or complete obstruction. The most common symptoms are epigastric or substernal pain, postprandial fullness, substernal fullness, nausea, and retching. An upright radiograph of the thorax may be diagnostic, revealing a retrocardiac air-fluid level within a

13paraesophageal hernia or intrathoracic stomach. Barium contrast studies are almost always diagnostic and attention should focus on the position of the EGJ in order to differentiate type II and III hernias. The natural history of a type II hernia is progressive enlargement so that the entire stomach eventually herniates, with the pylorus juxtaposed to the gastric cardia, forming an upside-down, intrathoracic stomach. Either as cause or effect, paraesophageal hernias are associated with abnormal laxity of structures normally preventing displacement of the stomach; the gastrosplenic and gastrocolic ligaments. As the hernia enlarges, the greater curvature of the stomach rolls up into the thorax. Because the stomach is fixed at the gastroesophageal junction, the herniated stomach tends to rotate around its longitudinal axis resulting in an organoaxial volvulus. Gastric volvulus may lead to acute gastric obstruction, incarceration, and perforation 5.Causes 1.Predisposing factors include the following: •Muscle weakening and loss of elasticity as people age is thought to predispose to hiatus hernia, based on the increasing prevalence in older people. With decreasing tissue elasticity, the gastric cardia may not return to its normal position below the diaphragmatic hiatus following a normal swallow. Loss of muscle tone around the diaphragmatic opening also may make it more patulous. •Hiatal hernias are more common in women. This may relate to the intra-abdominal forces exerted in pregnancy. •Burkitt et al suggest that the Western, fiber-depleted diet leads to a state of chronic constipation and straining during bowel movement, which might explain the higher incidence of this condition in Western countries. •Obesity predisposes to hiatus hernia because of increased abdominal pressure. •Conditions such as chronic esophagitis may cause shortening of the esophagus by causing fibrosis of the longitudinal muscles and, therefore, predispose to hiatal hernia. However, which comes first, the hiatal hernia worsening the reflux or the reflux-induced shortening of the esophagus, remains unknown. •The presence of abdominal ascites also is associated with hiatal hernias. 2.Diaphragmatic hernias may be congenital or acquired. Acquired hiatal hernias are divided further into nontraumatic and traumatic hernias. The most

14common types of hernias are those acquired in a nontraumatic fashion. Hernias acquired in a nontraumatic fashion are divided into 2 types, (1) sliding hiatal hernia and (2) paraesophageal hiatal hernia. A mixed variety with coexisting sliding and paraesophageal components is possible. •Sliding hiatal hernia by far is the most common type of hiatal hernia. It occurs when the gastroesophageal junction, along with a portion of the stomach, migrates into the mediastinum through the esophageal hiatus (see the image below). The majority of patients with demonstrated hiatal hernias are asymptomatic. This type of hernia interferes with the reflux barrier mechanism in several ways. As the LES moves into the chest, it no longer is exposed to positive intra-abdominal pressure and, therefore, is less effective as a sphincter. In fact, the sphincter moves into an area of low pressure, which interferes with the sphincter activity. In addition, the widening hiatus affects the competence of the diaphragmatic crura. The angle of His is lost, making regurgitation of gastric contents more likely. These changes not only predispose to reflux of gastric contents into the esophagus, but also prolong the acid contact time with the epithelium of the esophagus. •In paraesophageal hernia, also called rolling-type hiatal hernia, the widened hiatus permits the fundus of the stomach to protrude into the chest, anterior and lateral to the body of the esophagus; however, the gastroesophageal junction remains below the diaphragm (see Figure 3 of the image above). This causes the stomach to rotate in a counter-clockwise direction. As the hiatus widens, increasing amounts of the greater curvature of the stomach and, sometimes, the gastric-colic omentum, follow. The fundus eventually comes to lie above the gastroesophageal junction, with the pylorus being pulled towards the diaphragmatic hiatus. In this type of hernia, the anatomic relation of the stomach to the lower end of the esophagus (angle of His) tends to remain unchanged, so gross acid reflux does not occur. •6.Pathogeniesis The esophagus passes through the diaphragmatic hiatus in the crural part of the diaphragm to reach the stomach. The diaphragmatic hiatus itself is approximately 2 cm in length and chiefly consists of musculotendinous slips of the right and left diaphragmatic crura arising from either side of the spine and passing around the esophagus before inserting into the central tendon of the diaphragm. The size of the hiatus is not fixed, but narrows whenever intra-abdominal pressure rises, such as when lifting weights or coughing.[1] The lower esophageal sphincter (LES) is an area of smooth muscle approximately

152.5-4.5 cm in length. The upper part of the sphincter normally lies within the diaphragmatic hiatus, while the lower section normally is intra-abdominal. At this level, the visceral peritoneum and the phrenoesophageal ligament cover the esophagus. The phrenoesophageal ligament is a fibrous layer of connective tissue arising from the crura, and it maintains the LES within the abdominal cavity. The A-ring is an indentation sometimes seen on barium studies, and it marks the upper part of the LES. Just below this is a slightly dilated part of the esophagus, forming the vestibule. A second ring, the B-ring, may be seen just distal to the vestibule, and it approximates the Z-line or squamocolumnar junction. The presence of a B-ring confirms the diagnosis of a hiatal hernia. Occasionally, the B-ring also is called the Schatzki ring. Any sudden increase in intra-abdominal pressure also acts on the portion of the LES below the diaphragm to increase the sphincter pressure. An acute angle, the angle of His, is formed between the cardia of the stomach and the distal esophagus and functions as a flap at the gastroesophageal junction and helps prevent reflux of gastric contents into the esophagus (see the image below). Fig. 3 shows the normal relationship of the gastroesophageal junction, stomach, esophagus, and diaphragm. Figure 2 shows a sliding hiatal hernia where the stomach immediately below the gastroesophageal junction is seen to prolapse through the diaphragmatic hiatus into the chest. Figure 3 shows a paraesophageal hernia in which the cardia or fundus of the stomach prolapses through the diaphragmatic hiatus, leaving the gastroesophageal junction within the esophageal cavity. The gastroesophageal junction acts as a barrier to prevent reflux of contents from the stomach into the esophagus by a combination of mechanisms forming the antireflux barrier. The components of this barrier include the diaphragmatic crura, the LES baseline pressure and intra-abdominal segment, and the angle of His. The presence of a hiatal hernia compromises this reflux barrier not only in terms of reduced LES pressure but also reduced esophageal acid clearance. Patients with hiatal hernias also have longer transient LES relaxation episodes particularly at night time. These factors increase the esophageal mucosa acid contact time predisposing to esophagitis and related complications.

167.Diagnostic methods. •Preferred examination: Plain chest radiographs may demonstrate a retrocardiac gas-filled structure. An upper GI barium series is the preferred examination in the investigation of suggested hiatal hernia and its sequelae. CT scans are useful when more precise cross-sectional anatomic localization is desired. The use of magnetic resonance imaging (MRI) and radionuclide studies is anecdotal. Ultrasonography is a sensitive means of diagnosing gastroesophageal reflux, and it is particularly attractive for use in young patients because it is noninvasive and does not require the use of ionizing radiation.[2, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16] •Limitations of techniques The findings in an upper GI barium series may be specific, although the images may fail to demonstrate a small sliding hiatal hernia. Since gastroesophageal reflux may be intermittent, its presence may be overlooked. When no gas is present within the hernia, differentiating hernias from other retrocardiac masses may be difficult at times. Making the diagnosis of hiatal hernia using sonography is not always straightforward, and an intermittent hernia is likely to be missed; however, some physicians regard sonography as the examination of choice in infants because the findings may differentiate duodenal causes of vomiting from esophageal causes. 1.Radiography Most hiatal hernias are found incidentally on routine chest radiographs. The hernia may be seen as a retrocardiac mass with or without an air-fluid level. When air is seen within the hernia, the stomach air bubble found below the diaphragm tends to be absent. The hernia is usually positioned to the left of the spine; however, larger hernias (particularly incarcerated hernias) may extend beyond the cardiac confines and even mimic cardiomegaly. Most of these large hernias contain an air-fluid level and gastric contents. An air-fluid level may be absent in the hernia on supine radiographs; occasionally, differentiation from other retrocardiac masses may be difficult by using supine radiographs. Radiographs of hiatal hernias are depicted in the images below.

17 Fig. 4 A plain chest radiograph showing a well-defined, rounded, soft-tissue mass in the retrocardiac region consistent with a sliding hiatal hernia.
Fig. 5 A frontal chest radiograph in a patient with a large hiatal hernia demonstrating a retrocardiac opacity with radiolucent gas, which shifts the mediastinum to the right.

18 Fig. 6 A lateral chest radiograph showing a hiatal hernia. Note the absence of fundal gas below the left hemidiaphragm.
Fig. 7 A chest radiograph in a patient with a huge air-filled hiatal hernia, which appears as a mediastinal mass.

19•Upper GI barium series An upper GI barium series is the definitive method of diagnosing hiatal hernias (see the image below). A single-contrast barium swallow performed with the patient in the prone position is more likely to demonstrate a sliding hiatal hernia than an upright double-contrast examination. On double-contrast examination, areae gastricae can be recognized within the intrathoracic stomach.
Fig. 8 A barium-meal examination in a patient with a sliding hiatal hernia that demonstrates the supradiaphragmatic location of the gastroesophageal junction. If the mucosal B ring is more than 1-2 cm above the diaphragmatic impression, a sliding hiatal hernia is present. A sliding hiatal hernia may also be diagnosed by recognizing 5 or more mucosal folds that are more than 1-2 cm above the diaphragm on a single-contrast barium examination. A sliding hiatal hernia is reducible with the patient in an erect position. The hernia can often be recognized by the demonstration of mucosal gastric folds within the hernia. A hiatal hernia may cause deformity of the esophagus and/or fundus of the stomach. A tortuous esophagus may have an eccentric junction with the hernia. On a dynamic study, the esophageal peristaltic wave ceases above the hiatus; thus, the end of a peristaltic wave delineates the esophagogastric junction. An incarcerated hiatal hernia is believed to be present when a hernia remains fixed within the thorax and becomes irreducible.

20With a paraesophageal or rolling hernia, part of the stomach rolls into the thorax; usually, this occurs anterior to the esophagus. The hernia is frequently irreducible. A paraesophageal hiatal hernia is diagnosed by the position of the gastroesophageal junction. The cardia of the stomach-esophagogastric junction usually remains in the normal position below the diaphragmatic hiatus, and only the stomach herniates into the thorax, adjacent to the normally placed gastroesophageal junction. A double-contrast examination occasionally depicts an ulcer on the lesser curve of the stomach. Paraesophageal hernia is not usually associated with gastroesophageal reflux. A totally intrathoracic stomach is not a true hiatal hernia because herniation occurs through a defect in the central tendon of the diaphragm. The hernia is readily apparent on a single- or double-contrast barium swallow. The cardia is usually intrathoracic but it may occasionally be subdiaphragmatic. The greater curve of the stomach may lie either on the right or on the left. Gastroesophageal reflux or esophagitis often accompanies a hiatal hernia, and it may be depicted effectively on barium swallow scans.
Fig. 9 GE junction is below the esophageal hiatus Later, stomach protrudes through hiatus.

21 Fig. 10 On the left two examples. On the far left gas filled gastric fundus (asterisk) protrudes through hiatus but GE junction (arrow) is below diaphragm. Next to it a paraesophageal hernia with most of 'upside down' stomach in chest with greater curvature (arrows) flipped up. •Degree of confidence An upper GI barium series or barium swallow study is the examination of choice for depicting a hiatal hernia, gastroesophageal reflux, and any associated complications. •False positives/negatives A small sliding hiatal hernia may be missed by using a barium swallow or meal study. Other types of acquired or congenital diaphragmatic hernias, duplication cysts, neuroenteric cysts, neurogenic tumors, and the causes of paraspinal widening of soft tissues around the lower dorsal spine can all mimic the appearance of a hiatal hernia on plain radiographs. 2.Computed Tomography CT scanning is not routinely used in the diagnosis of a hiatal hernia, but it may be a useful for specific indications. Hiatal hernias often are seen incidentally on CT scans obtained for other indications (see the image below). A hiatal hernia appears as a retrocardiac mass with or without an air-fluid level. The mass can usually be traced into the esophageal hiatus on sequential cuts. Herniation of omentum through the esophageal hiatus may result in an increase in fat surrounding the lower esophagus.

22 Fig. 12 An axial CT scan of the thorax in a 75-year-old woman showing a retrocardiac mediastinal mass with a fluid level caused by a hiatal hernia.
CT scanning is particularly useful in the accurate anatomic depiction of a totally intrathoracic stomach, especially in patients in whom volvulus of the stomach is suspected. CT scanning is also useful for staging purposes in patients in whom a carcinoma complicates a hiatal hernia. Dehiscence of diaphragmatic crura of more than 15 mm may be seen.
Fig. 13 CT scan of the chest demonstrating a large paraesophageal hernia in retrocardiac area and dilated esophagus.

233.Magnetic Resonance Imaging MRI is not routinely used in the diagnosis of a hiatal hernia, and it offers no advantages over the dynamic capability of an upper GI barium series. MRI has helped to achieve a diagnosis of a paraesophageal omental hernia, in which a retrocardiac mass was shown as a fatty tumor, with contiguous blood vessels extending from the abdominal portion into the thoracic portion. Theoretically, conditions mimicking hiatal hernia on CT scans can mimic hiatal hernia on MRIs. 4.Ultrasonography In individuals without hiatal hernia, the gastroesophageal junction can almost always be depicted on ultrasonography with a cross-sectional diameter of 7.1-10.0 mm at the diaphragmatic hiatus level. The gastroesophageal junction is not depicted in a hiatal hernia, and the bowel diameter measured at the diaphragmatic hiatus is 16.0-21.0 mm. Each of the aforementioned signs has a predictive value of 100%. The negative predictive value of the bowel diameter is 90%, and failure to depict the gastroesophageal junction has a negative predictive value of 94.7%.
Fig. 14 Transverse section through the fetal chest at 37 weeks gestation. Taken at the level of the four-chamber heart, the fetal stomach (S) can be seen anterior to the spine (SP) and posterior to the right atrium. No cardiac or mediastinal shift is present. S: stomach, Sp: spine

24Fig. 15 On this longitudinal section taken at 37 weeks gestation, the sternum is up. The fetal stomach (S) is seen in the chest, posterior to the right ventricle (RV). S: stomach, RV: right ventricle, D: diaphragm •Degree of confidence Ultrasonography is a noninvasive technique that may be useful in the diagnosis of a hiatal hernia and gastroesophageal reflux. The use of ultrasonography is an attractive option in infants and young children in whom the images can help in differentiating esophageal causes of vomiting from duodenal causes. •False positives/negatives The predictive value of the criteria used in the evaluation of a sliding hiatal hernia in infants and young children is quite good; however, the criteria cannot be applied if the gastric fundus distal to the esophagus and gastroesophageal junction no longer lies within the abdominal cavity. One of the disadvantages of using ultrasonography for evaluating reflux is that sonograms poorly depict the severity of reflux, and sonograms are not sensitive for depicting esophagitis. An associated hiatal hernia, however, can be detected reliably. 5.Nuclear Imaging Radionuclides are not routinely used for the diagnosis of a hiatal hernia, but hiatal hernias may be incidentally found on whole-body radioiodine surveys performed in patients with thyroid cancer, in whom hernias may mimic metastatic cancer. Similarly, technetium-99m (99m Tc) pertechnetate and other99m Tc-labeled isotopes may depict a hiatal hernia incidentally. Oral99m Tc sulfur colloid scans and single photon emission computed tomography (SPECT) images may help in differentiating a hiatal hernia from metastatic thyroid cancer. Duodenogastric reflux in a hiatal hernia can be seen as retrocardiac activity on99m Tc-tetrofosmin cardiac SPECT raw-data images. Incidental findings such as extracardiac and retrocardiac activity in the thorax and abdomen should be included on all comprehensive cardiac SPECT reports.[17]

25Fig. 16 Anterior (A) and posterior (B) views of 99mTc-Sestamibi whole-body scan revealed no cervical bed uptake and an intense uptake of the radiotracer in the lower thoracic region (arrows) which may lead to the diagnosis of metastatic disease. Axial (C), sagittal (D) and coronal (E) thoracic SPECT images located this abnormal uptake in the lower thoracic midline (arrow heads). •False positives/negatives Theoretically, a duplication cyst or a neuroenteric cyst containing gastric mucosa may take up radioiodine or99m Tc compounds. 6.Angiography Hiatal hernia and esophagitis rarely produce massive GI tract hemorrhage; however, if this occurs, angiography may be able to depict the site of GI tract hemorrhage and the feeding blood vessels. •Degree of confidence Experience with angiography in hemorrhage from a hiatal hernia is limited, and the degree of confidence with which the diagnosis can be made is unknown. •False positives/negatives A false-negative diagnosis may occur if the gastric hemorrhage has temporarily stopped at the time of angiography (intermittent bleed) or if the rate of hemorrhage is slow. A false-positive diagnosis may occur when using digital subtraction angiography as bowel movements can be erroneously interpreted as hemorrhage.

26CHAPTER III – MATERIALS AND RESEARCH METHODS This chapter will include the discussion of two different articles that was performed by groups of doctors and researches to study more the role of Radiology in the diagnosis of hiatus hernia. The first article The title: The difference in clinical and barium radiographic findings for patients with large hiatal hernias and a floppy fundus with those patients with large hiatal hernias but no floppy fundus. Authors: Steven Y . Huang1, Marc S. Levine1, Stephen E. Rubesin1, David A. Katzka2 and Igor Laufer1. Patients and methods:
•Patient Population Through a computerized search of our radiology database we identified the cases of 99 patients with large hiatal hernias documented on barium studies performed with digital fluoroscopic equipment during the 7-year period 1998-2004. The images were reviewed at a computer workstation by consensus of two experienced gastrointestinal radiologists to confirm that the patients had large hiatal hernias. For the purposes of this study, a large hiatal hernia was defined as a hernia in which 25% or more of the stomach was located above the diaphragm. According to this criterion, six patients were excluded because less than 25% of the stomach was involved in the hernia. Another 15 patients were excluded because of previous esophageal or gastric surgery (e.g., Nissen fundoplication). The remaining 78 patients comprised the study group. •Examination Technique Fifty-four patients underwent double-contrast esophagography (n = 7) or double-contrast upper gastrointestinal examinations (n = 47) that included upright left posterior oblique double-contrast views of the esophagus and upright and recumbent double-contrast views of the stomach and duodenum obtained with an effervescent agent (Baros [dimethicone], Mallinckrodt) and 250% weight/volume barium (E-Z-HD, E-Z-EM) and prone right anterior oblique single-contrast views of the esophagus and recumbent single-contrast views of the stomach and duodenum obtained with 50% weight/volume barium (Entrobar, Mallinckrodt). The other 24 patients underwent single-contrast esophagography (n = 4) or single-contrast upper gastrointestinal examinations (n = 20) that included upright and recumbent single-contrast views of the esophagus, stomach, and duodenum obtained with 50% weight/volume barium (Entrobar). Recumbent views were not obtained for three of these patients.

27•Image Analysis and Study Design The images from all 78 barium studies were reviewed retrospectively at a computer workstation by consensus of the two gastrointestinal radiologists who had confirmed the presence of a large hiatal hernia. Blinded to the clinical findings, these radiologists reviewed the images to determine the size of the hiatal hernia (i.e., percentage of stomach in the thorax) and whether a floppy fundus was present. A floppy fundus was defined as a herniated fundus that drooped inferiorly as it filled with barium so that it was located beneath the most superior portion of the herniated gastric body. According to this criterion, 17 (22%) of the 78 patients with large hiatal hernias had a floppy fundus on barium studies. In the 17 patients in whom a floppy fundus was detected, the images were reviewed to determine the location of the floppy fundus, to determine whether the floppy fundus was detected on upright or recumbent views (upright and recumbent views of the floppy fundus were obtained for 14 patients with large hiatal hernias and upright or semiupright views for the other three), and to determine whether there was preferential filling of the floppy fundus with barium (defined as filling of the floppy fundus with barium before filling of the rest of the hernia). The original radiologic reports were reviewed to determine whether there was delayed emptying of barium from the floppy fundus or the rest of the herniated stomach (defined as slower than expected emptying of barium from the floppy fundus or rest of the hernia) and whether gastroesophageal reflux had been found at fluoroscopy. The reports also were reviewed to determine whether there was delayed emptying of the hernia in the 61 patients without a floppy fundus. One of the authors reviewed the medical records of all 78 patients to determine the nature and duration of presenting signs and symptoms. For the purposes of our study, mechanical symptoms related to the hernia were defined as those attributable to preferential filling or delayed emptying of the hernia and included postprandial pain, nausea, retching, and vomiting. To determine the treatment and patient course, medical records were reviewed for all 17 patients with large hiatal hernias and a floppy fundus and for 15 patients with mechanical symptoms who had large hiatal hernias without a floppy fundus. Clinical and radiographic data were recorded on separate protocol sheets to maintain blinding. Statistical analysis of the data was performed with Pearson's chi-square test or Fisher's exact test (S-Plus 4, Mathsoft). Statistical significance was considered p <0.05.

28The second article The title: Should Small Sliding Hiatal Hernias Be Reported at CT Colonography? The author: Perry J. Pickhardt1, Cody J. Boyce1, David H. Kim1, Louis J. Hinshaw1, Andrew J. Taylor1 2 and Thomas C. Winter1 3. Patients and methods: •Study Population This HIPAA-compliant study was approved by our institutional review board; the need for obtaining signed informed consent was waived for this retrospective analysis. The primary study group was derived from 3356 consecutive asymptomatic adults undergoing CTC screening at our institution between April 16, 2004, and November 6, 2006. A total of 230 cases were excluded because the level of the esophagogastric junction was not included on the supine series. The remaining 3126 individuals (1670 women, 1456 men) comprised the primary study group. The mean age of the study group was 57.0 ± 7.4 (SD) years. Among the patients with a hiatal hernia at CTC, medical record review identified 123 individuals (mean age, 60.9 years) who also underwent routine CT evaluation on a separate occasion that included the levels above and below the esophageal hiatus. This subgroup served as internal control subjects to assess the location of the esophagogastric junction. A total of 67 abdominal CT examinations were performed before CTC and 81 CT examinations were performed after CTC (25 patients had examinations both before and after CTC). For additional comparison, a separate group of 488 patients who underwent abdominal CT evaluation at our center between August 8, 2005, and October 4, 2005, served as external control subjects. The mean age of this cohort was 60.8 years and included 250 women and 238 men. The studies were performed for a variety of diagnostic indications. To allow for relevant comparison with routine CT, we evaluated only the supine CTC series for the presence of hiatal hernia.

29•CT Technique For the primary CTC screening cohort, imaging of the abdomen and pelvis was performed for the purpose of colorectal evaluation using colonography technique [7]. The preimaging protocol for colonography includes bowel preparation the evening before examination including both catharsis and oral contrast tagging. Of greatest relevance to this particular study, gaseous distention of the colon was performed using continuous automated low-pressure delivery of CO2, as previously described [8]. CT for colonography is performed during end-expiration to raise the diaphragm and minimize crowding of the splenic and hepatic flexures. Supine and prone acquisitions were obtained with an 8- or 16-MDCT scanner (LightSpeed Series, GE Healthcare) using 1.25-mm collimation, 120 kVp, static (50–75 mAs) or modulated (noise index = 50; range, 30–300 mA) tube current technique, and a 1-mm reconstruction interval. For extracolonic evaluation, the supine series was reconstructed with a 5-mm slice thickness at 3-mm intervals [9]. This supine series was used in this study to evaluate for the presence of hiatal hernia. For the internal and external abdominal CT control groups, standard diagnostic supine imaging used routine technique with scanning during end-inspiration. Colonic distention was not performed in any of these diagnostic CT studies. Fig. 17A Small hiatal hernia seen at CT colonography (CTC) screening in 67-year-old man that was not present on previous CT. Images from routine unenhanced chest CT examination performed 7 months before CTC shows no evidence of hiatal hernia. High-attenuation region with artifact is related to cardiac pacer lead.
Fig.17B Small hiatal hernia seen at CT colonography (CTC) screening in 67-year-old man that was not present on previous CT. Supine transverse and scout images from screening CTC show small sliding hiatal hernia. Note mass effect of gasdistended splenic flexure on stomach.

30 Fig.17C Small hiatal hernia seen at CT colonography (CTC) screening in 67-year-old man that was not present on previous CT. Supine transverse and scout images from screening CTC show small sliding hiatal hernia . Note mass effect of gasdistended splenic flexure on stomach.
•Hiatal Hernia Assessment Retrospective evaluation of the three CT study groups for the presence or absence of a sliding hiatal hernia was performed by one of six board-certified abdominal radiologists (all coauthors), all with at least 4 years of experience in abdominal CT interpretation. The three CT groups were assessed for hiatal hernia during separate reading sessions to reduce the potential for bias. Hiatal hernias identified in the internal control group were then directly compared with the index CTC to assess for interval change. Identification of gastric rugal folds, soft-tissue fullness separate from the tubular esophagus, a lobulated or irregular enteral contour above the esophageal hiatus, or a combination of these findings was the primary findings of a hiatal hernia at CT. If a hiatal hernia was present, the size was subjectively graded as small, moderate, or large.
Fig.18A Increase in size of sliding hiatal hernia at CT colonography (CTC) in 72-year-old woman. Image from routine unenhanced chest CT shows small sliding hiatal hernia. figure

31 Fig.18B Increase in size of sliding hiatal hernia at CT colonography (CTC) in 72-year-old woman. Supine transverse images from subsequent screening CTC show moderate-sized sliding hiatal hernia, increased from prior CT (A). Mild mass effect from colon on stomach is noted. After individual assessment of the three groups, the internal control group was directly compared with the corresponding CTC study to evaluate for a change in hernia size. If more than one routine CT study was available for the internal control group, the closest examination before or after CTC was used for calculation of the hernia reduction rate. •Statistical Analysis The Fisher exact test was used to test for group differences in discrete responses. A p value of less than 0.05 (two sided) was used as the criterion for statistical significance. Statistical calculations were performed using R software (version 2.10.0 [2009], R Development Core Team). To attempt to account for the effect of colonic distention at CTC, a size-specific correction factor was empirically derived and was applied to the baseline hernia rate using the results from the internal control group. Specifically, the percentage of hernias that resolved or decreased in size on the comparison routine CT (internal control group) was used to estimate the expected underlying baseline hernia rate at CTC, which was then compared with the external control group.

32CHAPTER IV – PERSONAL RESULTS AND DISCUSSION The results of the First article •Clinical Findings The mean age of the 17 patients with large hiatal hernias and a floppy fundus was 70.2 years (range, 51-91 years), and the mean age of the 61 patients with large hiatal hernias without a floppy fundus was 70.6 years (range, 30-96 years). All 17 patients with hernias and a floppy fundus were symptomatic; 10 (59%) of the 17 patients had mechanical symptoms related to the hernia, and 16 (94%) had other symptoms (Table 1). The mean duration of mechanical symptoms was 18.9 months (range, 2-96 months), and the mean duration of other symptoms was 17.2 months (range, 2-36 months). All 61 patients without a floppy fundus also had symptoms; 15 (25%) of the patients had mechanical symptoms related to the hernia, and 54 (89%) had other symptoms (Table 1). The mean duration of mechanical symptoms was 15 months (range, 0-72 months), and the mean duration of other symptoms was 21 months (range, 0-108 months). Thus, patients with a floppy fundus were significantly more likely to have mechanical symptoms than were those without a floppy fundus (p = 0.0075).
TABLE 1: Clinical Findings Among Patients with Large Hiatal Hernia With and Without a Floppy Fundus

33Radiographic Findings In all 78 patients with large hiatal hernias, the hernia included the gastric fundus and a portion of the gastric body. The percentage of the stomach contained in the hernia in patients with and those without a floppy fundus is summarized in Table 2.
TABLE 2: Radiographic Findings in Patients with Large Hiatal Hernia With and Without a Floppy Fundus The radiographic findings for the 17 patients with large hiatal hernias and a floppy fundus are summarized in Table 2 (Figs. 19A, 19B, 19C and 20). Of the 14 patients in whom upright and recumbent views were obtained, the floppy fundus persisted in the upright and recumbent positions in nine patients (53%) but intermittently returned to its expected location above the herniated gastric body in the recumbent position in the remaining five (29%) (Fig. 19C). Preferential filling of the floppy fundus with barium occurred in 11 (65%) of the 17 patients and delayed emptying of barium from the hernia in 16 (94%). Barium was retained within the floppy fundus in seven (44%) of these 16 patients (Figs. 19A and 20) and within the entire hernia in nine (56%). Gastroesophageal reflux was detected in 11 (65%) of the 17 patients. Delayed emptying of the hernia was found in only three (5%) of the 61 patients without a floppy fundus (p < 0.0001). Gastroesophageal reflux was detected in 47 (77%) of these patients. When the clinical findings were correlated with the radiographic findings for patients with large hiatal hernias, all 10 patients with mechanical symptoms and a floppy fundus had delayed emptying of the hernia on barium studies, whereas none of the 15

34patients with mechanical symptoms but no floppy fundus had delayed emptying of the hernia (p < 0.0001). In patients with a floppy fundus, mechanical symptoms related to delayed emptying of the hernia were present in seven (78%) of nine patients in whom the floppy fundus persisted throughout the study as opposed to three (60%) of five patients in whom the floppy fundus did not persist in the recumbent position. Treatment and Follow-Up The treatment and course of the patients in both groups are summarized in Table 1. Six (35%) of the 17 patients with a floppy fundus (including five of 10 patients with mechanical symptoms) underwent surgical repair of the hernia. The mean interval between the barium study and surgery was 1.8 months (range, 0.5-5.5 months). Three patients underwent open hernia repair, and three underwent laparoscopic repair. All six patients (including four with an unsuccessful trial of antisecretory agents) were free of symptoms a mean of 4.1 months after surgery (range, 0.5-18 months). Eleven (65%) of the 17 patients with a floppy fundus (including five of 10 with mechanical symptoms) received antisecretory agents (i.e., proton pump inhibitors). The symptoms resolved in only one (9%) of these 11 patients. This patient did not have mechanical symptoms. The other 10 (91%) of the patients, including five with mechanical symptoms, continued to have symptoms a mean of 30 months (range, 4-180 months) after starting treatment. One (7%) of the 15 patients who had mechanical symptoms without a floppy fundus underwent open surgical repair of the hernia. The interval between the barium study and surgery was 5 months. This patient was free of symptoms 3 months after surgery. Ten (67%) other patients who had mechanical symptoms without a floppy fundus were treated with antisecretory agents. Symptoms resolved in eight of these patients, but the other two continued to have symptoms 10 months after starting treatment. Four (26%) of the patients with mechanical symptoms did not undergo clinical follow-up. Discussion and Conclusion of the first article Sliding hiatal hernias result from migration of the gastric cardia and fundus through the esophageal hiatus of the diaphragm into the mediastinum [1, 9]. As these hernias enlarge, an increasing portion of the stomach enters the thorax, and barium studies typically show the gastric fundus at a higher position in the chest than the superiorly displaced gastroesophageal junction [5]. Although the fundus can be some-what caudal and inferior in patients with large hiatal hernias, we have observed a distinctive variation in which the herniated fundus droops inferiorly as it fills with barium, so that it is located well beneath the most superior portion of the herniated gastric body, a phenomenon that we have described as the floppy fundus (Figs. 19A, 19B, 19C and 20). In our study, a floppy fundus was detected on barium studies in 17 (22%) of 78 patients with large hiatal hernias.

35The development of a floppy fundus appears to be related to the size of the hiatal hernia. In our study, 12 (71%) of the 17 patients with a floppy fundus had a hiatal hernia containing 50% or more of the stomach, whereas only four (7%) of the 61 patients without a floppy fundus had a hernia containing 50% or more of the stomach (Table 1). These data suggest that a hiatal hernia reaches a critical threshold size before it is large enough for a floppy fundus to develop. When a floppy fundus was detected on barium studies, the floppy portion of the stomach was in a posterior location in 15 (88%) of the 17 patients and in an anterior location in two (12%). The floppy fundus was a persistent finding in the upright and recumbent positions in nine patients and an intermittent finding that did not persist in the recumbent position in five patients (Fig. 19A, 19B, 19C). Because mechanical symptoms related to the hernia were present in most of the patients in both groups, we conclude that such symptoms may develop whether or not a floppy fundus is seen throughout the barium study or does not persist in the recumbent position. Most patients with a hiatal hernia have either reflux symptoms or no specific symptoms related to the hernia [6]. Patients with large hiatal hernias occasionally have mechanical symptoms related to narrowing or twisting of the herniated portion of the stomach where it traverses the esophageal hiatus of the diaphragm [11]. In our series, however, 10 (59%) of the 17 patients with large hiatal hernias and a floppy fundus had mechanical symptoms (e.g., postprandial pain, early satiety, nausea, retching, and vomiting) related to distortion of the gastric anatomy, whereas such symptoms were present in only 15 (25%) of the 61 patients who had large hiatal hernias without a floppy fundus (p = 0.0075). We believe that these symptoms result from the mechanical effect of the accumulation of ingested food and liquids in the dependent portion of the flopped fundus, impeding emptying of the hernia. This view is supported by the observation that delayed emptying of the hernia was found on barium studies of 16 (94%) of the 17 patients with a floppy fundus versus only three (5%) of the 61 patients without a floppy fundus (p < 0.0001). Fig. 19A —66-year-old woman with postprandial chest pain and epigastric pain. Upright steep left posterior oblique radiograph from double-contrast upper gastrointestinal examination shows large hiatal hernia. Gastric fundus (large black arrows) has flopped inferiorly beneath most superior portion of gas-filled gastric body (large white arrow). Pooling of barium in floppy fundus is evident, as is small amount of barium spilling into portion of stomach (small black arrows) that traverses diaphragm. Small white arrow denotes location of gastroesophageal junction above diaphragm.

36 Fig. 19B —66-year-old woman with postprandial chest pain and epigastric pain. Supine steep left posterior oblique radiograph from same examination as A shows inferior location of floppy fundus (large black arrows) in relation to most superior portion of gastric body (small black arrow). Stomach (large white arrow) narrows where it traverses diaphragm. Small white arrow denotes location of gastroesophageal junction above diaphragm.
Fig. 19C —66-year-old woman with postprandial chest pain and epigastric pain. Prone right anterior oblique radiograph later in same examination as A and B shows gastric fundus (black arrows) in expected location above intrathoracic portion of gastric body so that fundus is no longer flopped inferiorly. White arrow denotes location of gastroesophageal junction above diaphragm. Symptoms resolved after laparoscopic reduction of hernia. When the clinical findings were correlated with the radiographic findings, all 10 patients with mechanical symptoms and a floppy fundus had delayed emptying of the hernias, whereas none of the 15 patients with mechanical symptoms but no floppy fundus had delayed emptying of the hernia (p < 0.0001). Thus, mechanical symptoms were significantly more likely to be associated with delayed emptying of the hernia in patients with a floppy fundus than in those without floppy fundus. On the other hand, the site of retention of barium in the hernia (the floppy fundus as opposed to the more distal portion of the hernia) varied in the 16 patients with a floppy fundus and delayed emptying of the hernia. Barium was retained in the floppy portion of the fundus in seven (44%) of the 16 patients and in the rest of the hernia in nine (56%). These data suggest that a floppy fundus may cause delayed gastric emptying either because of a mechanical effect of pooling of ingested food in the floppy fundus or because of subsequent traction on the stomach that impairs emptying of the hernia through the esophageal hiatus of the diaphragm.

37 Fig. 20 —61-year-old woman with nausea, regurgitation, postprandial epigastric pain, and early satiety. Upright steep right posterior oblique radiograph from double-contrast upper gastrointestinal examination shows retention of barium in floppy fundus (small arrows) with delayed emptying of hernia. Large arrow denotes narrowing of gastric body where it traverses diaphragm. Symptoms resolved after laparoscopic reduction of hernia. It is important to establish the diagnosis of a floppy fundus in patients with large hiatal hernias so that appropriate therapy can be instituted. In our series, all five patients with a floppy fundus and mechanical symptoms who underwent surgical repair of the hernia were free of symptoms a mean of 4.1 months after surgery. Conversely, all five patients with a floppy fundus and mechanical symptoms who were treated conservatively with antisecretory agents continued to have symptoms despite therapy. Despite our small sample sizes, these findings suggest that medical treatment often is not adequate for symptomatic patients with large hiatal hernias and a floppy fundus and that surgical repair of the hernia may be required. A larger prospective study is needed to further elucidate the optimal choice of therapy in this setting. Because the fundus is located inferior to the most superior portion of the herniated gastric body in patients with a floppy fundus, this configuration can be mistaken on barium studies for organoaxial gastric volvulus, a life-threatening condition because of the risk of incarceration, strangulation, and infarction of the involved stomach. In organoaxial gastric volvulus, however, most or all of the stomach herniates above the diaphragm into the lower thorax, the greater curvature of the stomach being rotated above the lesser curvature. The result is an upside-down intrathoracic stomach, often associated with twisting of the stomach where it traverses the esophageal hiatus of the diaphragm [3]. In contrast, normal anatomic relations are preserved in patients with a floppy fundus, and the distal portion of the stomach communicates normally with the duodenum below the diaphragm. Our investigation had the limitations of a retrospective study, including selection bias and possible inaccurate reporting of symptoms in the medical records. Our study also was limited by the relatively short duration of clinical follow-up (4.1 months) for patients with a floppy fundus who underwent surgical repair of the hernia. Another concern is that mechanical symptoms coincidentally may have been caused by abnormalities other than a floppy fundus in these patients. However, the response to

38treatment in patients who underwent surgical repair of the hernia suggests that the floppy fundus was responsible for the symptoms. conclusion patients with large hiatal hernias can develop a floppy fundus, which has a characteristic appearance on barium studies because it droops inferiorly beneath the most superior portion of the herniated gastric body. This phenomenon is relatively common, occurring in more than 20% of older persons with large hiatal hernias. Distortion of the gastric anatomy in these individuals can cause mechanical symptoms that usually resolve after surgical repair of the hernia. Radiologists should be aware of the findings associated with a floppy fundus on barium studies and of the potential role of surgery in the treatment of symptomatic patients with this condition. The results of the Second article A sliding hiatal hernia was present in 47.8% (1495) of the 3126 adults in the CTC screening cohort. Hernia size was categorized as small in 85.7% (1281/1495) of patients, moderate in 13.0% (194/1495), and large in 1.3% (20/1495). In some patients, the direct impact of the distended colonic on the proximal stomach was apparent (Figs. 17A, 17B, 17C, 182A, and 18B). Comparison abdominal CT of the 123 individuals with a hernia at CTC who served as internal control subjects showed resolution (i.e., absence) of the hernia in 64.2% (79/123), including 70.0% (70/100) and 47.4% (9/19) of small and moderate hernias, respectively (Figs. 17A, 17B, and 17C). None of the four large hernias among the internal control subjects at CTC was absent at comparison. Routine CT compared with CTC showed a reduction in hernia size in an additional 12 patients (Figs. 2A, and 2B). The timing of the CTC relative to comparison CT used for internal control did not meaningfully affect results: 77.6% (52/67) of hernias were smaller or absent on CT studies performed before CTC and 67.9% (55/81) of hernias were smaller or had resolved on CT performed after CTC (p = 0.202). Using these findings to estimate the underlying distribution of the CTC cohort, we assumed that 30% of small hernias, 53% of moderate-sized hernias, and 100% of large hernias would have been present without colonic distention. In addition, we assumed that 10% of moderate-sized hernias would decrease to become small without colonic distention to match the rate of hernias appearing small but not resolving completely among internal control subjects. The resulting estimated prevalence and size distribution after this “correction” are shown in Table 3, alongside the figures for the actual CTC cohort and the external control group.

39 TABLE 3: Prevalence and Size of Sliding Hiatal Hernias at CT Colonography (CTC) and CT The prevalence of sliding hiatal hernias in the external control group was 23.8% (116/488), significantly lower than the CTC cohort prevalence of 47.8% (p < 0.0001). These hernias were small in 83.6% (97/116), moderate in 12.1% (14/116), and large in 4.3% (5/116). After applying the correction factor for the CTC group, the estimated residual prevalence (16.2%) was much closer to that of the external control subjects especially when considering the younger age of the CTC group and the fact that the CTC group underwent end-expiratory imaging.
Discussion and Conclusion of the second article Our anecdotal observation that small sliding hiatal hernias appeared to be more common at CTC than other routine body CT examinations led us to conduct this study. Further motivation was provided by the concern for unnecessary patient anxiety or, perhaps even worse, for inappropriate management stemming from the reporting of this incidental and essentially physiologic finding. The potential for unnecessary workup already exists for the many “real” yet innocuous benign extracolonic findings seen at CTC [9]. An important responsibility of the radiologist interpreting CTC is to clearly indicate when an extracolonic finding may require further evaluation and also emphasize when additional workup is not needed. Our results show the casual relationship between CTC technique and small sliding hernias. Increased intraabdominal pressure from colonic distention inducing partial migration of the stomach through the esophageal hiatus makes intuitive sense and is somewhat analogous to using the Valsalva maneuver to intentionally accentuate abdominal wall hernias at CT [12]. The end-expiratory nature of image acquisition at CTC may further potentiate this effect. In a number of cases, direct mass effect of distended splenic flexure on the stomach could be seen (Figs. 17A, 17B, 17C, 18A, and 18B). The most compelling argument for causation of the hiatal hernia by colonic distention is the direct intrapatient comparison that typically shows the absence of the hernia that was seen at CTC on a separate routine CT in the same patient (Figs. 17A, 17B, and 17C). After excluding the estimated subset of small sliding hiatal hernias presumably related to colonic distention, the remaining prevalence of hiatal hernias at

40CTC screening appears to match well with the external control group, particularly when the expiratory technique, younger patient age, and presumed lack of symptoms among the CTC cohort are considered. Sliding, or type 1, hiatal hernias account for approximately 90–95% of all hiatal hernias identified at contrast fluoroscopy. Paraesophageal and combined sliding-paraesophageal hernias are much less common than sliding hiatal hernias but more often will give rise to symptoms and to potentially serious complications. Nonetheless, sliding hiatal hernias are relevant in terms of their relationship with GERD [5]. Although not a necessary precursor or a direct cause of reflux, hiatal hernias do appear to play a permissive role in some patients [4]. With few exceptions , endoscopic and radiologic studies have reported a notable increase in the prevalence of hiatal hernias in patients with reflux esophagitis (range, 35–94%) than in those without esophagitis (range, 8–60%). Possible explanations put forth for an increased susceptibility to reflux include an increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention , diminished pressure at the herniated esophagogastric junction , and an increase in strain-induced reflux events. Delayed clearance of acid reflux related to a hiatal hernia may also contribute [18]. Although the increased frequency of hiatal hernias among patients with reflux esophagitis is readily apparent from the literature, the actual prevalence in patients with esophagitis and in those without esophagitis is widely variable. Beyond any true differences in patient populations, the most important factors that affect prevalence estimates are likely the specific method used for hernia detection and the interobserver variation for a given method. Before the era of routine radiologic and endoscopic evaluations, hiatal hernia was considered to be a fairly rare condition with a much higher rate of symptoms [17]. Careful fluoroscopic evaluation generally results in higher reported frequencies compared with endoscopy, but interobserver variability for the detection of small hernias is likely quite high with both approaches. One study reported a high prevalence of hiatal hernias among patients undergoing laparoscopic surgery, but prevalence in that study may be artificially elevated because of increased intraabdominal pressure, much like that in our CTC cohort. Surprisingly little data exist about the CT diagnosis of small sliding hiatal hernia, with most attention focused on larger hernias [20]. As with fluoroscopy and endoscopy, the diagnosis of hiatal hernia is more straightforward when dealing with moderate-to-large hiatal hernias. Conclusion The positive predictive value (PPV) and negative predictive value of hiatal hernia for reflux esophagitis are largely determined by the prevalence of esophagitis in the study population. In the case of CTC screening, one might expect the PPV of hiatal hernia for predicting reflux esophagitis to be quite low given the asymptomatic nature of the cohort. The PPV should be further decreased by the physiologic nature of most small hernias seen at CTC, which again supports nonreporting of this finding. As an isolated finding, small and moderatesized sliding hiatal hernias do not warrant further workup or intervention, although clinical correlation for GERD symptoms would be reasonable. However, in the case of small

41hernias seen at CTC, any potential relevance is further diminished by the high likelihood that it was simply induced by the distention technique. We acknowledge several limitations to the current study. Assessment for the presence of small sliding hiatal hernias is somewhat subjective at CT like at fluoroscopy and endoscopy. It is possible that a prominent esophageal ampulla could be mistaken for a small hernia. However, any such inclusion should affect the control groups as well and serve to only raise the prevalence evenly among all three groups. The prevalence of GERD symptoms among the study groups is unknown. However, given the elective nature of outpatient CTC screening compared with diagnostic CT in generally symptomatic patients, the prevalence of symptoms was probably lower in the former cohort. Coupled with the fact that most of the small hernias at CTC are likely induced, the PPV for relevant GERD is expected to be very low. We did not evaluate for the presence of hiatal hernias on CTC studies obtained with the patient in the prone position largely because the CT examinations of the control groups for comparison consisted of only supine scans. However, based on experience at fluoroscopy, the frequency of hiatal hernias should be even higher while the patient is in the prone position relative to the supine position. Our practice of performing CTC acquisition during end-expiration may decrease the prevalence of small sliding hiatal hernias at CTC somewhat because of diaphragmatic elevation, increased intrathoracic pressure, and decreased intraabdominal pressure relative to inspiration. Finally, we did not measure the degree of gastric distention at CTC. Reflux of CO2 through the ileocecal valve occasionally will reach the level of the stomach, which may contribute to hernia formation in some cases. On the basis of our findings, we conclude that small transient sliding hiatal hernias are commonly induced by colonic distention at CTC and therefore should not be reported to avoid the potential for any undue anxiety or inappropriate patient management.

42CHAPTER V – CONCLUSION 1.Bone edema, erosions and synovitis are very early MRI findings of RA. MRI of the hand and wrist on clinical diagnosis of RA is useful to assess the degree of involvement. 2.The capitate, ulna, lunate, triquetrum, and scaphoid were the 5 bones most frequently demonstrating both baseline erosions and erosive progression. 3.Previous studies, by demonstrating very early the presence of anti-CCP antibodies and RF, have suggested that the disease process in RA starts long before the onset of symptoms, this study, by demonstrating bone erosions in VERA, reinforces this hypothesis. 4.The presence of bone edema in all patients with VERA. Bone edema is a pre- erosive lesion that represents true inflammation and can be seen on MRI alone or surrounding bone erosions.

43BIBLIOGRAPHY
1.Goyal Raj K, "Chapter 286. Diseases of the Esophagus". Harrison's Principles of Internal Medicine, 17e. 2.Burkitt DP (1981). "Hiatus hernia: is it preventable?" (PDF). Am. J. Clin. Nutr. 34 (3): 428–31. PMID 6259926. 3.Review article,magnetic resonance imaging in rheumatoid arthritis ,W.Travis, R. Rolim, A. Kakehasi-2010. Anderson MW, Kaplan PA, Dussault RG, Degnan GG. Magnetic resonance imaging of the wrist. Curr Probl Diagn Radiol 1998. 4.Fleson D.T. et al-American college of Rheumatology/ European league against Rheumatisim, Harrison’s principles of internal medicine 18th edition. 5.Goronzy J.J, Weyand CM: developments in the scientific understanding of rheumatoid arthritis 2009.Harrison’s principles of internal medicine 18th edition. 6.Myasoedova E et al: Epidemiology of rheumatoid arthritis:rheumatoid arthritis and mortality. 2010. Harrison’s principles of internal medicine 18th edition. 7.Types of synovial joints, kean university, anatomy of osteoarticular system Gray’s anantomy , the anatomical basis of clinical practice fortieth edition. 8.Goldring MB, Marcu KB: Cartilage hemostasis in the health and Rheumatoid disease. Arthritis 2009.Harrison’s principles of internal medicine 18th edition. 9.Goronzy J.J, Weyand CM: developments in the scientific understanding of rheumatoid arthritis 2009. Harrison’s principles of internal medicine 18th edition. 10.- Goldring SR, Goldrin MB: Eating bone or adding it: The Wnt pathway decides. 2007. Harrison’s principles of internal medicine 18th edition.

4411.Holers VM: Antibodies to citrullinated proteins: pathogenic and diagnostic significance.2007.Harrison’s principles of internal medicine 18th edition. 12.Mcinnes IB, Schett G: Cytokines in the pathogenesis of rheumatoid arthritis. Nat Rev Immunol 7, 2007 .Harrison’s principles of internal medicine 18th edition. 13.Joint involvement-the EULAR-OMERACT rheumatoid arthritis MRI studies of metacarpophalangeal joints, 2005 14.Steer S. The course of established rheumatoid arthritis. Best Pract Res Clin Rheumatol ,2007.Harrison’s principles of internal medicine 18th edition. 15.Neogi T et al: 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborativeinitiative. Arthritis Rheum, 2010.Harrison’s principles of internal medicine 18th edition. 16.Research Article, the usefulness of magnetic resonance imaging of the hand and wrist in early rheumatoid arthritis, Rheumatology clinic, department of internal medicine, medical school, university of ioannina, Greece. 17.Research Article, Patterns of magnetic resonance imaging Bone erosion in rheumatoid arthritis-which bones are most frequently involved and show the most change?, the journal of rheumatology 2011. 18.McQueen FM, Stewart N, Crabbe J, Robinson E, Yeoman S, Tan PL, McLean L: Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis 1998, 57:350-356.

45

4619.Nielen MM, van Schaardenburg D, Reesink HW, Twisk JW, van de Stadt RJ, van der Horst-Bruinsma IE, de Gast T, Habibuw MR, Vandenbroucke JP, Dijkmans BA: Increased levels of C-reactive protein in serum from blood donors before the onset of rheumatoid arthritis. Arthritis Rheum 2004, 50:2423-2427. 20.Jimenez-Boj E, Nöbauer-Huhmann I, Hanslik-Schnabel B, Dorotka R, Wanivenhaus AH, Kainberger F, Trattnig S, Axmann R, Tsuji W, Hermann S, Smolen J, Schett G: Bone erosions and bone marrow edema as defined by magnetic resonance imaging reflect true bone marrow inflammation in rheumatoid arthritis. Arthritis Rheum 2007, 56:1118-1124. 21.McQueen FM, Ostendorf B: What is MRI bone oedema in rheumatoid arthritis and why does it matter? Arthritis Res Ther 2006, 8:222. 22.McQueen FM, Ostendorf B: What is MRI bone oedema in rheumatoid arthritis and why does it matter? Arthritis Res Ther 2006, 8:222. 23.Hirohata S, Miura Y, Tomita T, Yoshikawa H, Ochi T, Chiorazzi N: Enhanced expression of mRNA for nuclear factor kappaB1 (p50) in CD34+ cells of the bone marrow in rheumatoid arthritis. Arthritis Res Ther 2006, 8:R54. 24.Schwarz EM, Looney RJ, Drissi MH, O’Keefe RJ, Boyce BF, Xing L, Ritchlin CT: Autoimmunity and bone. Ann N Y Acad Sci 2006, 1068:275-283. 25.Machold KP, Stamm TA, Nell VP, Pflugbeil S, Aletaha D, Steiner G, Uffmann M, Smolen JS: Very recent onset rheumatoid arthritis: clinical and serological patient characteristics associated with radiographic progression over the first years of disease. Rheumatology (Oxford) 2007, 46:342-349. 26.McQueen FM, Stewart N, Crabbe J, Robinson E, Yeoman S, TanPLJ, et al. Magnetic resonance imaging of the wrist in earlyrheumatoid

47arthritis reveals progression of erosions despite clinicalimprovement. Ann Rheum Dis 1999 27.Klarlund M, Østergaard M, Jensen KE, Madsen JL, Skjødt H, the TIRA group. Magnetic resonance imaging, radiography, andscintigraphy of the finger joints: one year follow up of patients with early arthritis. Ann Rheum Dis 2000; 28.Quinn MA, Conaghan PG, O’Connor PJ, Karim Z, Greenstein A,Brown A, et al. Very early treatment with infliximab in addition to methotrexate in early, poor-prognosis rheumatoid arthritis reduces magnetic resonance imaging evidence of synovitis and damage, with sustained benefit after infliximab withdrawal: results from a twelve- month randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2005; 29.Ejbjerg BJ, Vestergaard A, Jacobsen S, Thomsen H, Østergaard M. Conventional radiography requires a MRI-estimated bone volumeloss of 20% to 30% to allow certain detection of bone erosions inrheumatoid arthritis metacarpophalangeal joints. Arthritis Res Ther 2006 30.Østergaard M, Peterfy C, Conaghan P, McQueen F, Bird P, EjbjergB, et al. OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Core set of MRI acquisitions, joint pathology definitions, and the OMERACT RA-MRI scoring system. J Rheumatol 2003 31.Haavardsholm EA, Østergaard M, Ejbjerg BJ, Kvan NP, Uhlig TA,Lilleas FG, et al. Reliability and sensitivity to change of the OMERACT rheumatoid arthritis magnetic resonance imaging score in a multireader, longitudinal setting. Arthritis Rheum 2005 32.Cohen SB, Dore RK, Lane NE, Ory PA, Peterfy CG, Sharp JT, etal. Denosumab treatment effects on structural damage, bone mineral density, and bone turnover in rheumatoid arthritis: a twelve-month,

40multicenter, randomized, double-blind, placebo-controlled, phase II clinical trial. Arthritis Rheum 2008 33.Ejbjerg BJ, Vestergaard A, Jacobsen S, Thomsen HS, Østergaard M. The smallest detectable difference and sensitivity to change of magnetic resonance imaging and radiographic scoring of structuraljoint damage in rheumatoid arthritis finger, wrist, and toe joints: a comparison of the OMERACT rheumatoid arthritis magnetic resonance imaging score applied to different joint combinations and the Sharp/van der Heijde radiographic score. Arthritis Rheum 2005 34.Hetland ML, Stengaard-Pedersen K, Junker P, Ostergaard M, Ejbjerg BJ, Jacobsen S, et al. Radiographic progression and remission rates in early rheumatoid arthritis — MRI bone oedema and anti-CCP predicted radiographic progression in the 5-year extension of the double-blind randomised CIMESTRA trial. Ann Rheum Dis 2010 35.Duer-Jensen A, Vestergaard A, Døhn UM, Ejbjerg B, Hetland ML, Albrecht-Beste E, et al. Detection of rheumatoid arthritis bone erosions by two different dedicated extremity MRI units and conventional radiography. Ann Rheum Dis 2008 36.Duer-Jensen A, Ejbjerg B, Albrecht-Beste E, Vestergaard A, Dohn UM, Hetland ML, et al. Does low-field dedicated extremity MRI (E- MRI) reliably detect bone erosions in rheumatoid arthritis? A comparison of two different E-MRI units and conventional radiography with high-resolution CT scanning. Ann Rheum Dis2009 37.Døhn UM, Ejbjerg BJ, Hasselquist M, Narvestad E, Court- Payen,Szkudlarek M, et al. Rheumatoid arthritis bone erosion volumes on CT and MRI: reliability and correlations with erosion scores on CT, MRI and radiography. Ann Rheum Dis 2007 38.Bresnihan B: Pathogenesis of joint damage in rheumatoid arthritis. J Rheumatol 1999

4139.Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum 2010 40.Klarlund M, Ostergaard M, Gideon P, Sørensen K, Jensen KE, Lorenzen I: Magnetic resonance imaging, radiography, and scintigraphy of the finger joints: one year follow up of patients with early arthritis: the TIRA Group. Ann Rheum Dis 2000 41.McQueen FM, Stewart N, Crabbe J, Robinson E, Yeoman S, Tan PL,McLean L: Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis 1998 42.Ostergaard M, Hansen M, Stoltenberg M, Gideon P, Klarlund M, Jensen KE, Lorenzen I: Magnetic resonance imaging-determined synovial membrane volume as a marker of disease activity and a predictor of progressive joint destruction in the wrists of patients with rheumatoid arthritis. Arthritis Rheum 1999 43.Sugimoto H, Takeda A, Hyodoh K: Early-stage rheumatoid arthritis:prospective study of the effectiveness of MR imaging for diagnosis.Radiology 2000 44.Haavardsholm EA, Bøyesen P, Østergaard M, Schildvold A, Kvien Tk , Magnetic resonance imaging findings in 84 patients with early rheumatoid arthritis: bone marrow oedema predicts erosive progression.Ann Rheum Dis 2008 45.Benton N, Stewart N, Crabbe J, Robinson E, Yeoman S, McQueen FM: MRI of the wrist in early rheumatoid arthritis can be used to predict functional outcome at 6 years. Ann Rheum Dis 2004 46.Nell VP, Machold KP, Eberl G, Stamm TA, Uffmann M, Smolen JS: Benefit of very early referral and very early therapy with disease-

42modifying antirheumatic drugs in patients with early rheumatoid arthritis. Rheumatology (Oxford) 2004 47.Prevoo ML, van’t Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL: Modified disease activity scores that include twenty-eightjoint counts: development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995 48.Conaghan P, Bird P, Ejbjerg B, O’Connor P, Peterfy C, McQueen F, Lassere M, Emery P, Shnier R, Edmonds J, Østergaard M: The EULAROMERACT rheumatoid arthritis MRI reference image atlas: the metacarpophalangeal joints. Ann Rheum Dis 2005 49.McQueen FM, Benton N, Perry D, Crabbe J, Robinson E, Yeoman S, McLean L, Stewart N: Bone edema scored on magnetic resonance imaging scans of the dominant carpus at presentation predicts radiographic joint damage of the hands and feet six years later in patients with rheumatoid arthritis. Arthritis Rheum 2003 50.Nielen MM, van Schaardenburg D, Reesink HW, Twisk JW, van de Stadt RJ, van der Horst-Bruinsma IE, de Gast T, Habibuw MR, Vandenbroucke JP, Dijkmans BA: Increased levels of C-reactive protein in serum from blood donors before the onset of rheumatoid arthritis. Arthritis Rheum 2004 51.Jimenez-Boj E, Nöbauer-Huhmann I, Hanslik-Schnabel B, Dorotka R, Wanivenhaus AH, Kainberger F, Trattnig S, Axmann R, Tsuji W, Hermann S, Smolen J, Schett G: Bone erosions and bone marrow edema as defined by magnetic resonance imaging reflect true bone marrow inflammation in rheumatoid arthritis. Arthritis Rheum 2007 52.Navalho M, Resende C, Rodrigues AM, Gaspar A, Fonseca JE, Canhão H, Campos J: Dynamic contrast-enhanced 3-T magnetic

43resonance imaging: a method for quantifying disease activity in early polyarthritis. Skeletal Radiol 2011.