ARRS 2022 Abstracts

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E1738. Hiatal Hernia In Pediatric Age Group
Authors
  1. Ankita Chauhan; Le Bonheur Children's Hospital; University of Tennessee Health Science Center
  2. Stephen Miller; Le Bonheur Children's Hospital; University of Tennessee Health Science Center
  3. Jignesh Shah; Le Bonheur Children's Hospital; University of Tennessee Health Science Center
  4. Roger Austin Dillard; Le Bonheur Children's Hospital; University of Tennessee Health Science Center
Background
Gastroesophageal reflux refers to a passage of stomach contents into the esophagus with or without vomiting and is a normal physiologic process occurring in infants and less often in older children. When reflux causes troublesome symptoms or medical complications, it is termed gastroesophageal reflux disease (GERD). Most infants grow out of regurgitation by 12 months of age by making a few changes in the way they are fed (such as small feeds, use of thickening agents). Older children require lifestyle modification (such as avoiding late evening meals and sleep position changes). When medical therapy fails to relieve symptoms, surgical intervention such as Nissen’s fundoplication is considered. It is vital to detect anatomic abnormalities, such as hiatal hernia before surgery, as the management changes.

Educational Goals / Teaching Points
Our exhibit will discuss the congenital and acquired disease conditions involving the gastroesophageal junction in children, primarily focusing on hiatal hernia. Our exhibit will demonstrate the pathophysiology and the classic imaging appearances of different types of hiatal hernia in the pediatric age group. We will briefly discuss the surgical interventions to help understand the imaging appearances of the stomach and gastroesophageal junction after successful and failed anti-reflux procedures.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
In a hiatal hernia (HH), elements of the abdominal cavity (most commonly stomach) herniate through the esophageal hiatus into the mediastinum. It is crucial to identify the type of HH and comment upon its size. Four types are described: type I (most common) is associated with the phreno-esophageal membrane's laxity; type II (paraesophageal) hernias are uncommon in children and are believed to result from a persistent right pneumoenteric recess; type III hernias are a combination of the first two types; and type IV HH is when a few organs herniate through a large defect in the phrenoesophageal membrane. Ultrasound (US) is the first-line examination in children younger than 2 years and can help exclude anatomic causes such as hypertrophic pyloric stenosis or HH. To identify a hiatal hernia, one should remember that the gastroesophageal junction (GEJ) location is dynamic, and that the esophageal hiatus does not always correlate with the diaphragmatic shadow. Barium swallow examination helps identify and characterize hiatal hernia that changes surgical management. Radiologists should also be familiar with post-fundoplication radiographic findings and postoperative complications (like recurrent hernia, intrathoracic migration of the wrap).

Conclusion
A hiatal hernia should be excluded in all patients with gastroesophageal reflux, especially before anti-reflux procedures as it changes surgical management. Barium esophagography remains the initial imaging study in pediatric patients with dysphagia, vomiting, and failure to thrive. Understanding the pathophysiology and recognizing the imaging findings of different types of hiatal hernia will help to ensure timely intervention.