What type of CT (Computed Tomography) scan should I order for a suspected hiatal hernia?

Appropriate CT Scan for Suspected Hiatal Hernia

For suspected hiatal hernia, CT is not the recommended first-line imaging test; instead, fluoroscopic studies (biphasic esophagram, single-contrast esophagram, or upper GI series) are the most appropriate initial imaging studies. 1, 2

Recommended Imaging Approach for Hiatal Hernia

• Fluoroscopic studies are the most useful tests for diagnosing hiatal hernia, with three equivalent options:

  • Biphasic esophagram
  • Single-contrast esophagram
  • Upper GI series (double-contrast) 1, 2

• Double-contrast upper GI series is particularly beneficial as it:

  • Detects presence and size of hiatal hernia
  • Provides anatomic and functional information on esophageal length
  • Identifies esophageal strictures
  • Evaluates for gastroesophageal reflux and reflux esophagitis 1

• Single-contrast esophagram may be considered in some instances, though it may not reveal mucosal irregularities from reflux disease 1

When CT is Appropriate for Hiatal Hernia

If CT is still desired despite the above recommendations:

• CT abdomen with IV contrast may be considered, though it is controversial and has insufficient literature support for routine use in hiatal hernia 1

• CT with IV contrast provides superior visualization compared to non-contrast CT when evaluating:

  • Relationship between hernia and cardiac structures
  • Potential complications such as ischemia
  • Vascular abnormalities 2, 3

• Non-contrast CT chest can identify a hiatal hernia but offers limited assessment of:

  • Vascular structures
  • Potential complications such as ischemia or strangulation 2

Special Considerations

• If the hiatal hernia is large, include an upper GI series evaluation for complete assessment of the stomach 1

• In pregnant patients with suspected hiatal hernia, ultrasonography is recommended as the first diagnostic study, followed by MRI if necessary, to avoid radiation exposure 2, 3

• For patients with suspected complications or when evaluating the relationship between the hernia and cardiac structures, CT with IV contrast is preferred over non-contrast CT 2, 3

Common Pitfalls to Avoid

• Ordering CT as first-line imaging for hiatal hernia when fluoroscopic studies are more appropriate and informative 1, 2

• Using non-contrast CT when vascular assessment is needed, particularly when evaluating the relationship between the hernia and cardiac structures 2

• Failing to include upper GI series evaluation when a large hiatal hernia is suspected 1

• Relying solely on plain radiography, which has limited sensitivity for hiatal hernia diagnosis 4