Large Hiatal Hernia with Floppy Fundus: Clinical and Radiographic Findings

Radiography of Hiatal Hernia Gastrointestinal Imaging Clinical Observations Steven Y. Huang 1 Marc S. Levine 1 Stephen E. Rubesin 1 David A. Katzka 2 Igor Laufer 1 Huang SY, Levine MS, Rubesin SE, Katzka DA, Laufer I Keywords: barium, gastrointestinal imaging, hernia, stomach DOI:10.2214/AJR.05.1209 Received July 12, 2005; accepted after revision September 18, 2005. 1 Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Address correspondence to M. S. Levine (marc.levine@uphs.upenn.edu). 2 Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA. AJR 2007; 188:960 964 0361 803X/07/1884 960 American Roentgen Ray Society Large Hiatal Hernia with Floppy Fundus: Clinical and Radiographic Findings OBJECTIVE. The purpose of this study was to compare the clinical and barium radiographic findings for 17 patients with large hiatal hernias and a floppy fundus with those for 61 patients with large hiatal hernias but no floppy fundus. CONCLUSIONS. Patients with large hiatal hernias can develop a floppy fundus, which has a characteristic appearance on barium studies because it droops below the most superior portion of the herniated gastric body. Distortion of the gastric anatomy in patients with this type of hernia can cause mechanical symptoms that usually resolve after surgical repair of the hernia. Radiologists should be aware of the barium radiographic findings associated with a floppy fundus and of the potential role of surgery in the treatment of patients with symptoms. he most common type of gastric T hernia is a hiatal hernia, in which weakening of the phrenoesophageal membrane and gradual enlargement of the esophageal hiatus of the diaphragm allow the gastric cardia and fundus to herniate through the diaphragm into the thorax [1 5]. The prevalence of hiatal hernias increases with age; 60% of elderly persons in the United States are found to have a hiatal hernia on barium studies [6]. As the hernia enlarges, it becomes important to differentiate a giant hiatal hernia from a paraesophageal hernia and gastric volvulus, conditions more likely to be associated with clinically important complications such as obstruction, incarceration, and strangulation [2, 3, 6 9]. When barium studies are performed on patients with large hiatal hernias, the fundus can droop below the herniated gastric body, producing a distinctive radiographic appearance that we describe as a floppy fundus. To our knowledge, this entity has not been reported in the radiology literature. The purpose of our investigation was to assess the clinical and barium radiographic findings in a series of patients with large hiatal hernias and a floppy fundus in comparison with the findings in patients with large hiatal hernias but no floppy fundus. Materials and Methods Institutional Review Board Approval Our institutional review board approved all aspects of this retrospective study and did not require informed consent from patients included in the study. 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 960 AJR:188, April 2007

Radiography of Hiatal Hernia TABLE 1: Clinical Findings Among Patients with Large Hiatal Hernia With and Without a Floppy Fundus Floppy Fundus (n = 17) No Floppy Fundus (n = 61) Finding No. % No. % Mechanical symptoms related to hernia 10 59 15 25 Postprandial pain 5 13 Early satiety 5 2 Retching 5 3 Nausea 4 3 Vomiting 3 5 Other signs and symptoms 16 94 54 89 Reflux symptoms a 11 25 Iron-deficiency anemia 5 17 Dysphagia 4 14 Belching 3 1 Weight loss 2 2 Treatment b Surgical repair 6 35 1 7 Mechanical symptoms 5 1 No mechanical symptoms 1 0 Clinical response 6 1 Medical therapy 11 65 10 66 Mechanical symptoms 5 10 No mechanical symptoms 6 0 Clinical response 1 8 No clinical follow-up 0 4 27 a Including heartburn, substernal burning, and regurgitation. b Clinical follow-up only obtained for patients with large hiatal hernias but no floppy fundus who had mechanical symptoms related to the hernia (n = 15). 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. 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. Results 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). Radiographic 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. The radiographic findings for the 17 patients with large hiatal hernias and a floppy fundus are summarized in Table 2 (Figs. 1 and 2). 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. 1C). 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 AJR:188, April 2007 961

TABLE 2: Radiographic Findings in Patients with Large Hiatal Hernia With and Without a Floppy Fundus Floppy Fundus (n = 17) No Floppy Fundus (n = 61) Finding No. % No. % Percentage of stomach in hernia 25 50 5 29 57 93 50 75 8 47 4 7 > 75 4 24 0 0 Location of floppy fundus Posterior 2 12 Posterior and to right 8 47 Posterior and to left 5 29 Anterior and to left 2 12 Patient position for floppy fundus a Upright and recumbent 9 53 Upright only 5 29 Delayed emptying 16 94 3 5 From floppy fundus 7 0 From entire hernia 9 3 Gastroesophageal reflux 11 65 47 77 a Upright and recumbent views were obtained for 14 (82%) of the 17 patients with large hiatal hernias and a floppy fundus. 16 patients (Figs. 1A and 2) 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 patients 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 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 somewhat 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. 1 and 2). In our study, a floppy fundus was detected on barium studies in 17 (22%) of 78 patients with large hiatal hernias. The 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. 1). 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 [1 3, 6, 10]. 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 15]. 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 ef- 962 AJR:188, April 2007

Radiography of Hiatal Hernia fect 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). 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 A C 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 Fig. 1 66-year-old woman with postprandial chest pain and epigastric pain. A, 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. B, 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. C, 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. B AJR:188, April 2007 963

Fig. 2 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. 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. 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 [2, 3, 6 9]. 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, 7]. 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 treatment in patients who underwent surgical repair of the hernia suggests that the floppy fundus was responsible for the symptoms. In summary, 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. 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