Hiatus hernia differential diagnosis: Difference between revisions

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[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].


==Differentiating X from other Diseases==
==Differentiating hiatus hernia from other diseases==
*[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
*Hiatus hernia presents as [[gasytroesophagela reflux disease]](GERD) with dysphagia and must be differentiated from other causes of dysphagia:{| class="wikitable"
*[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Disease
! colspan="8" align="center" style="background:#4479BA; color: #FFFFFF;" |Signs and Symptoms
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Barium esophagogram
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Endoscopy
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Other imaging and laboratory findings
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Gold Standard
|-
| rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Onset
| colspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Dysphagia
| rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Weight loss
| rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Heartburn
| rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Other findings
| rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Mental status
|-
| align="center" style="background:#4479BA; color: #FFFFFF;" |Solids
| align="center" style="background:#4479BA; color: #FFFFFF;" |Liquids
| align="center" style="background:#4479BA; color: #FFFFFF;" |Type
|-
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Plummer-Vinson syndrome
|Gradual
| +
| -
|Non progressive
| +/-
| -
|
* [[Glossitis]]
 
* [[Koilonychia]]


*As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].
|Normal
|
* Thin projections on the anterior [[esophageal]] wall
* Multiple upper[[Esophageal stricture|esophageal constrictions]]
|
* Direct visualization of [[esophageal webs]]
* Superior to [[esophagogram]]
|
* Videofluoroscopy shows [[mucosal]] and [[submucosal]] foldings


===Preferred Table===
|
{|
Triad of
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
* [[Iron deficiency anemia]]
! rowspan="2" |Diseases
* [[Esophageal webs]]
! colspan="4" |History and Symptoms
* [[Glossitis]]
! colspan="4" |Physical Examination
! colspan="4" |Laboratory Findings
! rowspan="2" |Other Findings
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
!Finding
1
!Finding 2
!Finding 3
!Finding
4
!Physical Finding 1
!Physical Finding 2
!Physical Finding 3
!Physical Finding 4
!Lab Test 1
!Lab Test 2
!Lab Test 3
!Lab Test 4
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 1
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Esophageal stricture]]
| style="background: #F5F5F5; padding: 5px;" |
|Gradual or sudden
| style="background: #F5F5F5; padding: 5px;" |
| +
| style="background: #F5F5F5; padding: 5px;" |<nowiki>+</nowiki>
| -
| style="background: #F5F5F5; padding: 5px;" |
|Progressive
| style="background: #F5F5F5; padding: 5px;" |
| +/-
| style="background: #F5F5F5; padding: 5px;" |
| +/-
| style="background: #F5F5F5; padding: 5px;" |
|
| style="background: #F5F5F5; padding: 5px;" |
* [[Odynophagia]]
| style="background: #F5F5F5; padding: 5px;" |
* [[Cough]]
| style="background: #F5F5F5; padding: 5px;" |
 
| style="background: #F5F5F5; padding: 5px;" |
* [[Chest pain]]
| style="background: #F5F5F5; padding: 5px;" |
|Normal
| style="background: #F5F5F5; padding: 5px;" |
|
*Sacculations
*Fixed transverse folds
*[[Esophageal]] intramural pseudodiverticula   
|
* [[Mucosal]] edema
* Circumferential thickening in [[Gastroesophageal reflux disease|GERD]]
* Pale [[mucosa]] with white [[exudate]] in lymphocytic esophagitis
 
* [[Swelling]] and [[hemorrhagic]] [[congestion]] in [[caustic]]<nowiki/>ingestion
|
* [[Manometry]] may show dysmotility
* [[CT scan]] for staging [[malignant]] [[strictures]]
|
* [[Esophagogram|Barium esophagogram]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 2
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Diffuse esophageal spasm]]
| style="background: #F5F5F5; padding: 5px;" |'''↑'''
|Sudden
| style="background: #F5F5F5; padding: 5px;" |
|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" | -
|Non progressive
| style="background: #F5F5F5; padding: 5px;" |
|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
|
| style="background: #F5F5F5; padding: 5px;" |
* [[Chest pain]]
| style="background: #F5F5F5; padding: 5px;" |
 
| style="background: #F5F5F5; padding: 5px;" |
|Normal
| style="background: #F5F5F5; padding: 5px;" |
|
| style="background: #F5F5F5; padding: 5px;" |
* Nonperistaltic and nonpropulsive contractions
| style="background: #F5F5F5; padding: 5px;" |
* Corkscrew or rosary bead esophagus
|
* Inconclusive
|
*[[Manometry]] shows high-amplitude [[esophageal]] contractions
*[[CT scan]] may show [[hypertrophy]] of esophageal muscles
|
* [[Manometry]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 3
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Achalasia]]
| style="background: #F5F5F5; padding: 5px;" |
|Gradual
| style="background: #F5F5F5; padding: 5px;" |↓
| +
| style="background: #F5F5F5; padding: 5px;" |
|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
|Non progressive
| style="background: #F5F5F5; padding: 5px;" |
| +/-
| style="background: #F5F5F5; padding: 5px;" |
| -
| style="background: #F5F5F5; padding: 5px;" |
|
| style="background: #F5F5F5; padding: 5px;" |
* [[Regurgitation]] of undigested food
| style="background: #F5F5F5; padding: 5px;" |
* [[Chest pain]]
| style="background: #F5F5F5; padding: 5px;" |
|Normal
| style="background: #F5F5F5; padding: 5px;" |
|
| style="background: #F5F5F5; padding: 5px;" |
* "Bird's beak" or "rat tail" appearance
| style="background: #F5F5F5; padding: 5px;" |
* Dilated esophageal body
* Air fluid level (absent [[peristalsis]])
* Absence of an intragastric air bubble
|
* Dilated [[esophagus]]
* Residual food fragments
* Normal [[mucosa]]
|
* Residual pressure of [[Lower esophageal sphincter|LES]] > 10 mmHg
* Incomplete relaxation of the [[Lower esophageal sphincter|LES]]
* Increased resting tone of [[Lower esophageal sphincter|LES]]
* Aperistalsis
|
* History of [[dysphagia]] with positive [[endoscopy]] and [[manometry]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 4
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Systemic sclerosis]]
| style="background: #F5F5F5; padding: 5px;" |
|Gradual
| style="background: #F5F5F5; padding: 5px;" |
| +
| style="background: #F5F5F5; padding: 5px;" |
|<nowiki>+</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
|Progressive
| style="background: #F5F5F5; padding: 5px;" |
| +/-
| style="background: #F5F5F5; padding: 5px;" |
| +
| style="background: #F5F5F5; padding: 5px;" |
|
| style="background: #F5F5F5; padding: 5px;" |
* [[Muscle pain|Muscle]] and [[Arthralgia|joint pain]]
| style="background: #F5F5F5; padding: 5px;" |
 
| style="background: #F5F5F5; padding: 5px;" |
* [[Raynaud's phenomenon]]
| style="background: #F5F5F5; padding: 5px;" |
 
| style="background: #F5F5F5; padding: 5px;" |
* [[Skin changes]]
| style="background: #F5F5F5; padding: 5px;" |
|Normal
|
* Dysmotility
 
* Patulous [[esophagus]]
|
* [[Mucosal]] damage
 
* [[Peptic]] stricture (advanced cases)
|Positive serology for
* [[Antinuclear antibodies]]
 
* [[Rheumatoid factor]]
 
* [[Creatine kinase]]
 
* [[ESR]]
|
* [[Skin biopsy]]
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Differential Diagnosis 5
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Zenker's diverticulum]]
| style="background: #F5F5F5; padding: 5px;" |
|Gradual
| style="background: #F5F5F5; padding: 5px;" |
| +
| style="background: #F5F5F5; padding: 5px;" |
|<nowiki>-</nowiki>
| style="background: #F5F5F5; padding: 5px;" |
|
| style="background: #F5F5F5; padding: 5px;" |
| +/-
| style="background: #F5F5F5; padding: 5px;" |
| -
| style="background: #F5F5F5; padding: 5px;" |
|
| style="background: #F5F5F5; padding: 5px;" |
* Food [[regurgitation]]
| style="background: #F5F5F5; padding: 5px;" |
 
| style="background: #F5F5F5; padding: 5px;" |
* [[Halitosis]]
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
| style="background: #F5F5F5; padding: 5px;" |
|}


===Use if the above table can not be made===
* [[Coughing|Cough]]
{| style="border: 0px; font-size: 90%; margin: 3px; width: 1000px" align="center"
 
| valign="top" |
* [[Hoarseness]]
|+
|Normal
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Differential Diagnosis}}
|
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Similar Features}}
* Thin projections on [[esophageal]] wall over [[Killian's dehiscence|Killian's triangle]]
! style="background: #4479BA; width: 300px;" | {{fontcolor|#FFF|Differentiating Features}}
|
* Outpouching of posterior [[pharyngeal]] wall
 
* Exclude the presence of [[Squamous cell carcinoma|SCC]] 
|
* [[CT]] & [[MRI]] shows out-pouching over the posterior esophagus in the Killian's triangle
|
* Barium [[Esophagogram|esophagography]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 1
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Esophageal carcinoma]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|Gradual
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
|<nowiki>+</nowiki>
| style="padding: 5px 5px; background: #F5F5F5;" |
|<nowiki>+</nowiki>
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|Progressive
| +
|<nowiki>+/-</nowiki>
|
* [[Lymphadenopathy]]
 
* [[Cachexia]]
|Normal
|
* Irregular [[Strictures|stricture]]
* Pre-stricture [[dilatation]]
|
* [[Esophageal]] obstruction
* Staging of disease
|
* [[CT]] and [[PET scan]] is an optional test for staging of the disease
|
* [[Biopsy]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 2
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Stroke]]
| style="padding: 5px 5px; background: #F5F5F5;" |
([[Cerebral hemorrhage]])
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
|Sudden
| style="padding: 5px 5px; background: #F5F5F5;" |
|<nowiki>+</nowiki>
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|<nowiki>+</nowiki>
|Progressive
|<nowiki>+</nowiki>
|<nowiki>+/-</nowiki>
|
* [[Dysarthria]]
 
* Limb [[weakness]]
 
* [[Fatigue]]
|Impaired
|
* Pooling of [[Contrast medium|contrast]] in the [[pharynx]]
* [[Aspiration]] of [[barium]] [[Contrast medium|contrast]] into the [[airway]]
|
* Reduced opening of [[upper esophageal sphincter]]
* Reduced [[larynx]] elevation
|
* [[CT]] without [[contrast]] shows acute [[hemorrhage]] as a hyperattenuating [[clot]]
|
* [[CT]] without [[Contrast medium|contrast]]
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 3
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |Motor disorders
| style="padding: 5px 5px; background: #F5F5F5;" |
([[Myasthenia gravis]])
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
|Gradual
| style="padding: 5px 5px; background: #F5F5F5;" |
| +
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
| +
|Progressive
|<nowiki>+/-</nowiki>
|
|
* [[Ptosis]]
* [[Diplopia]]
* [[Fatigue]]
|Normal
|
* Stasis in [[pharynx]] and pooling in pharyngeal recesses
|
* [[Velopharyngeal insufficiency]]
* Delayed [[swallowing]] function
|
* CT may show anterior [[mediastinal]] mass ([[thymoma]])
* Positive tensilon test
|
* Anti–acetylcholine receptor antibody test
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 4
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[GERD]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|Gradual or
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
 
| style="padding: 5px 5px; background: #F5F5F5;" |
sudden onset
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
| +
| -
|Progressive
| +/-
| +
|
* [[Cough]]
 
* [[Hoarseness]]
|Normal
|
* Free acid reflux
* [[Esophagitis]] with scarring
* [[Strictures]]
* [[Barrett's oesophagus]]
|
* [[Erythema]], erosions and [[ulceration]]
* [[Barrett's esophagus]]
|
* Esophageal [[manometry]] may show decreased tone of [[Lower esophageal sphincter|LES]]
|
* 24 hour [[esophageal]] pH monitoring
|-
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Differential 5
| style="padding: 5px 5px; background: #DCDCDC;" align="center" |[[Esophageal web]]
| style="padding: 5px 5px; background: #F5F5F5;" |
|Gradual
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].
| +
| style="padding: 5px 5px; background: #F5F5F5;" |
| +/-
* On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
|Progressive
| -
| +/-
|
* Findings of the underlying cause such as [[iron deficiency anemia]] or [[bullous pemphigoid]]
|Normal
|
* Symmetrical narrowing of the [[esophagus]]
|
* Smooth membrane not encircling the whole [[Lumen (anatomy)|lumen]]
|
* Videofluoroscopy shows [[mucosal]] and [[submucosal]] foldings
|
* Barium [[esophagogram]]
|}
|}


Revision as of 16:22, 7 February 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Differentiating hiatus hernia from other diseases

! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Disease ! colspan="8" align="center" style="background:#4479BA; color: #FFFFFF;" |Signs and Symptoms ! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Barium esophagogram ! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Endoscopy ! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Other imaging and laboratory findings ! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Gold Standard |- | rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Onset | colspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Dysphagia | rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Weight loss | rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Heartburn | rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Other findings | rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Mental status |- | align="center" style="background:#4479BA; color: #FFFFFF;" |Solids | align="center" style="background:#4479BA; color: #FFFFFF;" |Liquids | align="center" style="background:#4479BA; color: #FFFFFF;" |Type |- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Plummer-Vinson syndrome |Gradual | + | - |Non progressive | +/- | - |

|Normal |

|

|

| Triad of

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Esophageal stricture |Gradual or sudden | + | - |Progressive | +/- | +/- |

|Normal |

  • Sacculations
  • Fixed transverse folds
  • Esophageal intramural pseudodiverticula   

|

|

|

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Diffuse esophageal spasm |Sudden |+ |+ |Non progressive |+ |+ |

|Normal |

  • Nonperistaltic and nonpropulsive contractions
  • Corkscrew or rosary bead esophagus

|

  • Inconclusive

|

|

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Achalasia |Gradual | + |+ |Non progressive | +/- | - |

|Normal |

  • "Bird's beak" or "rat tail" appearance
  • Dilated esophageal body
  • Air fluid level (absent peristalsis)
  • Absence of an intragastric air bubble

|

|

  • Residual pressure of LES > 10 mmHg
  • Incomplete relaxation of the LES
  • Increased resting tone of LES
  • Aperistalsis

|

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Systemic sclerosis |Gradual | + |+ |Progressive | +/- | + |

|Normal |

  • Dysmotility

|

  • Peptic stricture (advanced cases)

|Positive serology for

|

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Zenker's diverticulum |Gradual | + |- | | +/- | - |

|Normal |

|

  • Exclude the presence of SCC 

|

  • CT & MRI shows out-pouching over the posterior esophagus in the Killian's triangle

|

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Esophageal carcinoma |Gradual |+ |+ |Progressive | + |+/- |

|Normal |

|

|

  • CT and PET scan is an optional test for staging of the disease

|

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Stroke (Cerebral hemorrhage) |Sudden |+ |+ |Progressive |+ |+/- |

|Impaired |

|

|

|

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Motor disorders (Myasthenia gravis) |Gradual | + | + |Progressive |+/- | |

|Normal |

  • Stasis in pharynx and pooling in pharyngeal recesses

|

|

|

  • Anti–acetylcholine receptor antibody test

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |GERD |Gradual or

sudden onset | + | - |Progressive | +/- | + |

|Normal |

|

|

|

|- | style="padding: 5px 5px; background: #DCDCDC;" align="center" |Esophageal web |Gradual | + | +/- |Progressive | - | +/- |

|Normal |

|

  • Smooth membrane not encircling the whole lumen

|

|

|}

References

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