Mideyi içeren hiatal herni BT bulguları

Özet

Hiatal hernide mide ve/veya gastroözofageal bileşke diyaframın özofageal hiatusundan toraksa yer değiştirir. BT, herni içindeki mide bölümünü, bileşkenin konumunu ve eşlik eden organları çok düzlemli olarak gösterir; komplikasyonsuz küçük kaymalar sıklıkla rastlantısaldır. Büyük paraözofageal hernide mide rotasyonu, obstrüksiyon, duvar perfüzyon kaybı veya perforasyon gelişebilir. Bu bulguların atlanması akut volvulus ve mide iskemisinin tanınmasını geciktirebilir.

Faz ve pencere

Portal tanısal: Portal venöz kontrastlı toraks-abdomen BT'de mide fundusu veya daha geniş bölümü diyafram üstünde, özofagus yanında ya da posterior mediastende izlenebilir; gastroözofageal bileşkenin hiatusa göre yeri tip ayrımını sağlar. Kontrastlanan mide duvarında azalmış/heterojen kontrastlanma, çevresel sıvı ve serbest hava eşlik ederse iskemi veya perforasyon şüphesi artar.

Önerilen pencereler: Mediasten (G 350 / M 50), Batın (G 400 / M 50), Yumuşak doku (G 400 / M 40).

BT bulguları

Diyafram kruralarının oluşturduğu hiatus üstünde mide duvarı veya lümeni görülür.
Tip I kaymada gastroözofageal bileşke ve kardiya yukarı yer değiştirir; paraözofageal tipte fundus özofagusun yanında yükselirken bileşke aşağıda kalabilir.
Tip III'te hem bileşke hem fundus yukarıdadır; tip IV'te mideye ek olarak başka karın içi organlar toraksa geçer.
Herniye mide intratorasik hava-sıvı seviyeleri ve kardiyomediastinal komşulukla izlenebilir.
Volvulusta büyük-küçük kurvatur ilişkisi ters dönebilir ya da antropilorik bileşke gastroözofageal bileşkenin üzerine taşınabilir.
Hernia boynunda daralma, pilor düzeyinde geçiş noktası ve proksimal mide distansiyonu obstrüksiyonu destekler.
Duvar hipo-kontrastlanması, pnömatozis, perigastrik sıvı veya serbest hava iskemik hasar/perforasyon açısından alarm bulgusudur.

Ölçütler ve sınıflamalar

Hiatal herni anatomik tipleri: Tip I: gastroözofageal bileşke yukarı kayar. Tip II: fundus özofagus yanında yukarı çıkar, bileşke normal yerindedir. Tip III: bileşke ve fundus birlikte herniye olur. Tip IV: mideye ek olarak başka bir karın içi organ hiatus üzerinden toraksa çıkar.
Gastrik volvulus eksen tipleri: Organoaksiyel: rotasyon uzun eksen çevresindedir ve büyük kurvatur küçük kurvaturun üzerine/sağına geçebilir. Mezenteraksiyel: kısa eksen çevresinde rotasyonda antropilorik bileşke gastroözofageal bileşkenin üzerine yer değiştirir. Mikst tipte iki eksenin bulguları birliktedir.

Normalde

Normalde gastroözofageal bileşke hiatus düzeyinde, fundus ve korpus ise diyafram altında bulunur; mide duvarı hiatusun üzerine uzanmaz. Kıyaslarken bileşke, kardiya ve fundusun kruslara göre konumunu; herni içindeki midenin kurvatur yönünü, geçiş açıklığını ve duvar kontrastlanmasını birlikte değerlendir.

Normal BT ile kıyasla

Aynı bölgenin, kaynak veri setinde patoloji içermediği belirtilen bir BT incelemesini kesit kesit kaydırın; organ sınırlarını açarak anatomiyi hasta görüntüsüyle karşılaştırın. Küçük rastlantısal bulgular tümüyle dışlanmamıştır.

Kaynak: TotalSegmentator v2.01 veri seti (Wasserthal ve ark., Radiology: Artificial Intelligence 2023), CC BY 4.0, vaka s0546; organ sınırları veri setinin otomatik segmentasyonundan, birleştirilerek sadeleştirildi. Görüntüler 2,5 mm kesit aralığına yeniden örneklendi.

Ayırıcı tanı

Epifrenik özofagus divertikülü: BT ile mide lümeni dışında, GE bileşke üzerindeki özofagus distalinde lokalize yapı olarak izlenir; normalde distal özofagus diyaframin yaklaşık 2 cm altındadır.
Mediastinal kist: BT ile doku kompozisyonu, vaskülerizasyonu ve mediastenal yapılarla ilişkisi değerlendirilerek özofageal herniden ayırılır; kontraslı BT boşluk ve damarları net gösterir.
Sol diyafram eventrasyonu: BT ile kubbeyi yükselten faktörler detaylıca değerlendirilir; bu görüntüleme bulguları, potansiyel organ göçlerini ve cerrahi öncesi planlamayı belirler.
Mide volvulusu olmaksızın büyük hiatal herni: toraksa yer değiştirmiş mide vardır ancak belirgin rotasyon, geçiş noktası veya obstrüksiyon işareti yoktur.

Tuzaklar

Küçük, aralıklı kayan hernide BT anında GE bileşke diyafram düzeyinde görünebilir; normalde distal özofagus diyaframin yaklaşık 2 cm altındadır ve bileşkenin kruslara göre yeri tip ayrımını sağlar.
Geniş hernide yön değiştirmiş fundus toraksta kitle gibi görünebilir; BT ile midenin trilaminar duvar görünümü ve adequate distansiyonda 5 mm altı duvar kalınlığı izlenerek mediyenal kitlerden ayırılır.
Volvulusun tek bir eksen işareti duyarsız olabilir; herni boynu darlığı ve pilorik geçiş noktası gibi obstrüksiyon işaretlerini ayrıca ara.
Kontrastlanmanın azalması tek başına kesin nekroz değildir; komşu duvarla kıyasla ve pnömatozis, sıvı, duvar ödemi ile birlikte yorumla.

Kendini dene

Fundus özofagus yanında toraksa çıkmış, gastroözofageal bileşke hiatus altında kalmış. Herni tipi hangisidir?
Cevabı göster
Tip II paraözofageal. Tip II'de fundus paraözofageal olarak yükselir, bileşke yerinde kalır. Tip I'de bileşke yukarı kayar; tip III'te ikisi birlikte yükselir; tip IV'te ek karın organı herniye olur.
İntratorasik midede kurvatur ters dönmüş, pilorda geçiş noktası ve boyunda daralma var. En önemli eşlik eden süreç hangisidir?
Cevabı göster
Gastrik volvulus. Yönelimi değişmiş mide ile pilorik geçiş ve hernia boynu darlığı volvulus/obstrüksiyonu destekler. Diğer seçenekler mide rotasyonu ve geçiş noktası oluşturmaz.

İlgili konular

Midenin normal görünümü ve distansiyon varyantları

Kaynaklar

Bu sayfadaki 45 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 5 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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