Paraözofageal hiatal herni (tip II–IV)

Özet

Paraözofageal hernide mide fundusunun bir bölümü özofagusun yanından hiatusa çıkar; tip II'de gastroözofageal bileşke normal yerinde kalırken tip III'te o da toraksa yükselir. Büyük intratorasik mide, herni inkarsere olduğunda mide çıkışına ve duodenuma belirgin retansiyonla ilişkili olabilir. BT'de hiatal herninin anatomisi ve mide volvulusu bulguları değerlendirilebilir; akut olguda mide duvarı iskemisi veya ileri hasar bulguları araştırılır. İnkarserasyon veya strangülasyona bağlı iskemi ve perforasyon bulguları gözden kaçarsa ciddi mide duvarı hasarı fark edilmeyebilir.

Faz ve pencere

Kontrastsız tanısal

Kontrastsız BT'de diyafram üstündeki herni kesesi ve intratorasik mide değerlendirilir; çok düzlemli görüntülerde mide fundusu ile gastroözofageal bileşkenin konumu incelenebilir.

Venöz

Akut komplikasyon şüphesinde kontrastlı BT'de mide duvarında kontrastlanma kaybı ve pnömatozis gibi iskemi veya ileri duvar hasarı bulguları araştırılır.

BT bulguları

• Hiatusun yanında torasik fundus — diyafram kruslarının üstünde, distal özofagusun yanında yer alan mide lümeni.
• GE bileşke yerinde, fundus yukarıda — tip II paraözofageal yerleşimin ayırt edici anatomisi.
• GE bileşke ve midenin bir bölümü birlikte mediastene uzanır — tip III görünümü.
• Mide dışı organın herni kesesine girmesi — kolon, ince bağırsak, omentum veya başka visseral içeriği araştırın.
• Herni boynunda stenoz ve pilorda geçiş noktası — mide volvulusunda görülebilen BT bulguları.
• Mezenterioaksiyel volvulusta antrumun fundusla aynı seviyede veya daha kraniyalde olması ve pilorda geçiş noktası tanısal BT bulgularıdır.
• Mide duvarında fokal kontrastlanma kaybı veya pnömatozis — iskemi ya da ileri duvar hasarını düşündüren BT bulguları.
• Volvulus kuşkusunda mide rotasyonunu organoaksiyel veya mezenterioaksiyel olarak tanımlayın; mide yönelimiyle birlikte herni boynundaki darlığı ve pilordaki geçiş noktasını değerlendirin.

Ölçütler ve sınıflamalar

Paraözofageal hiatal herni tip II–IV

Tip II: fundus hiatus yanından toraksa çıkar, GE bileşke normal konumdadır. Tip III: hem GE bileşke hem fundus torakstadır ve fundus bileşkenin üzerindedir. Tip IV: mideye ek olarak başka bir karın organı herni kesesine girer.

Normalde

Normalde distal özofagusun yaklaşık 2 cm'lik bölümü diyafram altında yer alır; hiatal hernide mide özofageal hiatus üzerinden toraks içine protrüde olur. Hiatusu sagittal ve koronal düzlemde izleyerek fundusun özofagus yanından geçip geçmediğini, bileşkenin yerini ve herni içeriğinin mide dışı organ içerip içermediğini kıyaslayın.

Ayırıcı tanı

Tip I kayıcı hiatal herni

GEJ diyafram üstüne kayar; fundus da genellikle birlikte toraks içinde yer alır.

Epifrenik divertikül distal özofagusla ilişkili bir divertiküldür ve özofagus motilite bozukluklarıyla ilişkili olabilir.

Mediastinal neoplazmlar ayırıcı tanıda düşünülebilir; hiatal hernide pankreas herniasyonu kuşkusunda splenik damarların ve sol gastrik arterin toraksa uzanışını gösteren “vascular loop” bulgusu mediastinal neoplazmdan ayırıma yardımcı olabilir.

Mide pull-up rekonstrüksiyonu

cerrahi anastomoz ve rezeksiyon sonrası değişmiş mide anatomisiyle ayırt edilir.

Tuzaklar

• Tip II ile tip III ayrımı için gastroözofageal bileşkenin yerini ve mide fundusunun uzanımını sagittal ve koronal BT görüntülerinde değerlendirin.
• Herni içindeki mide gazı retro-kardiyak opasite olarak mediastinal kitleyi taklit edebilir; toraks içindeki yerleşimi ve hiatusla devamlılığı BT ile doğrulayın.
• Herni kesesindeki kolon veya ince bağırsak tip IV'ü düşündürür; toraks içindeki her gazlı visserayı mide olarak adlandırmayın.
• Geniş herni tek başına volvulusu göstermez; mide yönelimiyle birlikte herni boynu stenozunu ve pilordaki geçiş noktasını değerlendirin.

Kendini dene

1. Fundus hiatus yanından toraksa çıkmış, ancak GE bileşke diyafram altında normal yerinde. Bu hangi tiptir?

   • Tip II paraözofageal
   • Tip I kayıcı
   • Tip III karma
   • Tip IV
   Cevabı göster

   Tip II paraözofageal. Tip II'de fundus özofagus yanında herniye olurken GE bileşke yerinde kalır. Tip I'de bileşke yükselir; Tip III'te fundusla bileşke birlikte yükselir; Tip IV'te mide dışı organlar da keseye katılır.

2. İntratorasik mideye ek olarak transvers kolonun da herni kesesinde olduğu görülüyor. Sınıflama nedir?

   • Tip IV hiatal herni
   • Tip II paraözofageal
   • Tip III karma
   • Tip I kayıcı
   Cevabı göster

   Tip IV hiatal herni. Mide dışı bir karın organının herni kesesine girmesi tip IV tanımına uyar. Diğer tipler kolon gibi ek visseral içeriği içermez.

İlgili konular

• Hiatal herni
• Hiatal herniye eşlik eden mide volvulusu

Kaynaklar

Bu sayfadaki 41 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 12 cümle bu karşılaştırmada düzeltildi (2026-10-10).

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