1. HERNIA THROUGH OESOPHAGEAL
HIATUS IN FETUS – A RARE
CAUSE OF CONGENITAL
DIAPHRAGMATIC HERNIA
Dr Irfan A. Kazi MD[RD]
Radiologist,
Sonosquare Ultrasound Clinic, Hyderabad

2. Introduction
 Congenital diaphragmatic hernia [CDH] is a
herniation of abdominal contents into chest cavity. It
can be through
 Foramen of Bochdalek-posterior diaphragmatic defect
 Foramen of Morgagni-anterior diaphragmatic defect
 Uncommonly, herniation through oesophageal hiatus or
due to diaphragmatic agenesis

3. Clinical presentation
 A 25 yr old 2nd gravida, with one normal child aged 2yrs, came to our clinic for TIFFA
at 21wks of gestation
 On USG, the fetal cardiac axis was abnormal & the fetal heart was displaced to the
extreme left of the thorax.
 The entire stomach was herniating into the thorax through a postero-medial
diaphragmatic defect on the left of midline thereby displacing the heart.
 These features were suggestive of diaphragmatic hernia, through the oesophageal
hiatus.
 Both the lungs were mildly compressed.
 Right lung area : head circumference ratio(LHR) was 2.1
 Heart was structurally normal
 There was no pericardial or pleural effusion
 Liver and portal veins were seen in the abdomen on the right side
 No other obvious abnormalities were seen. The liquor was normal

4. Coronal view of thorax and abdomen
Superior
Left
Right
Coronal view of thorax and abdomen
Superior
Left
Right
In the coronal images, the stomach
is seen in the midline, the heart on
the left and the liver is seen in the
abdomen. The ductus venosus is
splayed to the left of midline as the
heart is displaced to extreme left
HEA-Heart St-Stomach
DV- Ductus venosus D-Diaphragm
RL- Right lung LIV- Liver

5. ant
left
stomach stomach
ant
right
Heart
The image above shows a hernia
through the oesophagial hiatus in which
the heart is displaced to the extreme left
The image above shows a CDH through the
left diaphragm (Bochdalek’s Hernia) in which
the heart is displaced towards the right side

6. Discussion
Left sided hernia
 Four classic findings
 Cystic mass on left side of chest
 Absence of fluid filled stomach
 Deviation of heart towards right
 Polyhydramnios
 Upto 85 % contain herniated liver
Right sided hernia
 Contains liver and bowel(doppler
shows portal veins)
 Stomach is below diaphragm (may
be more in the midline)
 Gall bladder may also be herniated
Bilateral
 Stomach is in the chest with no
mediastinal shift
 Colour doppler will show liver
with portal veins on doppler
Hernia through oesophageal hiatus
 Stomach is in the midline in the thorax
 Heart is deviated to the extreme left-
helps diffferentiate from left sided
hernia
 The liver is seen in the abdomen- helps
differentiate from right sided hernia

7. DD for CDH
Other cystic masses
 Bronchogenic cyst
 Oesophageal duplication cyst
 Neurenteric cyst
-All Are rare
-more often associated with
mediastinum than lung
CCAM
 If it is of macrocystic type
 diaphragm is intact
 Stomach is below diaphragm
 Doppler shows pulmonary
arterial vascular supply
Hybrid lesion
 Combination of CCAM &
sequestration
 To be considered when cystic
mass is fed by systemic vessel
Teratoma
 Solid & cystic components
 Calcifications are seen

8. Prognosis
 65% survival if isolated
 Poor prognostic factors:
 Other abnormalities
 Liver in chest
 Large size
 Right sided/bilateral
 LHR<1.0
LHR [lung:head ratio]
 Area of contralateral lung/head circumference
 Lung area is calculated by multiplying 2 orthogonal cross sectional lung
measurements taken at the level of 4 chamber view
 LHR<1.0 poor prognosis
 >1.4good prognosis
 Nowadays 3D softwares are available in USG & MRI which are better indicators
of lung volume than LHR
Treatment
 Indications for intrauterine treatment:
 Herniation of liver
 LHR<1.0
 Intrauterine intervention-
 PLUG-plug lung until it grows
 FETO-fetoscopic tracheal occlusion
 Delivery by caesarean using ex-utero
intrapartum treatment[ EXIT] if intrauterine
intervention is done