Types 4-6 (Reflux, Hiatus Hernia)

Follow-up in an infant with repeated esophagogastography due to vomiting. On the left and right at the top at the age of 1 month: The stomach is visible as a rounded contrast accumulation at the bottom; on both sides at the top there is contrast in the esophagus and in a cavity lying in between. On the left side at the bottom in the further follow-up: The stomach lying normally on the right at the bottom is now smaller; instead of it, there is a contrast filling of a large structure lying above and further cranially of the somewhat twisted esophagus. On the right side at the bottom only shortly afterwards: The stomach is not recognizable at the normal site; instead of it a large cavity filled with contrast is visible without a seizable lesser and greater gastric curvature (compare with the left picture at the top). It is a severe gastroesophageal reflux reaching to the upper third (compare the picture on the left at the bottom) combined with a hiatus hernia. The severity grade of the hiatus hernia increases during infancy from a permanent epiphrenic gastric pouch to a so-called upside-down stomach, which means that the whole stomach ends up lying upside-down in the thorax. In the first three pictures the stomach is recognizable as such in a normal position. On the other hand, in the last picture this is not true anymore; the lesser gastric curvature corresponds to the lower and the greater to the upper contour lying within the thorax. Combined with this morphological follow-up there is also a change of the clinical signs because due to displacement and torsion of the stomach the voiding of the stomach as well as the entry into the stomach may be impaired: Gastric retention and dysphagia replace chronic vomiting.