A large hiatal hernia is almost always associated with organoaxial torsion, with the degree of torsion having a direct relationship to the size of the hernia.Up to a 180-degree twist is present if most of the stomach is in the chest. In spite of the torsion, gastric volvulus develops only in a minority of these patients; a more common problem is obstruction at the hiatus.
One of the less common causes of a diaphragmatic hernia is prior surgery. As one example, transdiaphragmatic gastric herniation developed after coronary artery bypass using a right gastroepiploic artery. Occasionally Tc-99m-pertechnetate scintigraphy, performed for other indications, will demonstrate an unsuspected diaphragmatic hernia.
An ulcer is not uncommon in a hiatal hernia; these ulcers are notoriously difficult to detect with a barium study (Fig. Below). A perforating ulcer in a hernia involves any adjacent structure, including pericardium and left ventricle. Cancers also develop in hiatal hernias (Fig. below).
stomach tends to rotate and, as in this patient, the greater curvature
has rotated 180 degrees and is superior to the lesser curvature.
Such a twist predisposes to gastric volvulus.
Adenocarcinoma (arrows) in a large hiatal hernia.
A sliding hiatal hernia and ulcer (arrow) at the hiatus. Adenocarcinoma (arrows) in a large hiatal hernia