Your next patient is a 68 year old female with mild dyspnoea. On examination, she is stable with mild epigastric tenderness only. You obtain chest x-ray as part of your investigation and the x-rays are here.

Looking at the PA view, you are beginning to wonder if you are dealing with a left diaphragmatic hernia. Here is the lateral view. What can you see?

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The PA chest view shows distended stomach with air fluid level in the left hemithorax. The lateral view shows fluid/air filled stomach in retrocardiac position. There is a large hiatus hernia.

Hiatus hernia can be of 2 types :

• Sliding – Commonest, the gastro-oesophageal junction is above the diaphragm. Predisposes to reflux, oesophagitis.
• Para oesophageal – Portion of the stomach lies above the diaphragm after herniating through the oesophageal hiatus but the gastro-oesophageal junction lies below the diaphragm. Can lead to life threatening complications like volvulus or strangulation.

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