1. Hiatal Hernia Radiology case presentation 8/17/07

2. Patient background 63 year old female HPI: Recent months complaining of symptoms of dysphagia especially solids(bread). Pain in the epigastric region in supine and aggravated with the valsalva.

3. PMH Hiatal hernia Type III Abnormal esophageal Motility and LES mamometry. Recurrent Pneumonia and SOB Collis Nissen repair in 2004.

4. Differential diagnosis Achalasia Chaga’s dz: Trypanosomiasis Scleroderma: fribrotissue replacement of muscle Phrenic ampulla ( corresponds to the location of LES Epiphrenic diverticulum Post surgical change

5. Comorbid conditions Diverticulum (25%) Esophageal dysmotility

6. Diverticulum

7. Peristalsis Teritary contractions present. ? Nissen or at least should make the nissen less tight to avoid dyphagia.

8. Characteristics of hernia B ring wrap “above” the diaphragm wrap “above” the diaphragm Railroad track: Magenstrassa Plan film: can demonstrate air fluid level in area of heart.

9. Note the cystic structure (ant. Herniation)

10. B ring (z line) squamocolumnar conjunction (green arrow) Anatomic: at ridge of gastroesophogeal junction (Crus)

11. Hernia from different angle Hernia Diaphragm

12. Ba pill Ba pill versus solution - picture demonstrates solid dysphagia Wrap

13. Patient’s hospital course Patient seen as outpatient and to be evaluated with EDG before final decision to be made.

14. Reference Mettler, F. (2005). Essentials of Radiology 2nd ed. USA: Saunders. Retrieved July 31 2007 from Mdconsult online electronic medical library: http://www.mdconsult.com http://www.mdconsult.com