Hiatal Hernia: Explanation of Chest X-Ray Findings

The typical radiograph is of a well-defined, rounded, retrocardiac opacity with an air-fluid level. In this image, the radiolucent gas is highlighted in blue, while the gastric contents are highlighted in the green. In many cases of hiatal hernia, there will not be an air bubble below the left hemidiaphragm. This is a relatively expected finding considering that the stomach is no longer in its usual position. The anatomical position of the herniated organ can be further elucidated on the lateral radiograph. Here we can see that the stomach is in the middle mediastinum posterior to the heart and above the diaphragm. Hiatal hernias can look similar to a retrocardiac lung abscess or another cavitary lesion, but it will change in size and shape between radiographs. Large hernias can shift the mediastinum to the right and result in a widening of the carinal angle. They can even give the appearance of cardiomegaly. In this radiograph, the cardiac silhouette is distinctly visible within the confines of the hiatal hernia. To review, a hiatal hernia on an AP chest radiograph typically appears as a round retrocardiac opacity with an air-fluid level.

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