Aman, age 81 years, presented with frequent nausea and non-bloody vomiting for the past week, and a 3-day history of worsening epigastric abdominal pain with no flatus or bowel movements. He was tachycardic (120 bpm) and hypotensive (86/40 mm Hg). Upper abdomen was profoundly tender and distended. Laboratory results were significant for leukocytosis (20 × 103/uL; normals 4.1–10.9 × 103/uL), acute kidney injury (creatinine 1.8 mg/dL; normals 0.6–1.3 mg/dL), and lactic acidosis (lactate 6.0 mmol/L; normals 0.5–2.1 mmol/L). Chest radiograph demonstrated air-filled loops of the colon over the midline of the lower thorax (figure 1). Abdominal computed tomography confirmed type IV hiatal hernia (figures 2 and 3). The patient received aggressive hemodynamic resuscitation in the intensive care unit. Exploratory laparotomy with hernia reduction and extended right hemicolectomy, due to extensive colonic necrosis, was performed. Gastrostomy tube was placed.
Portable upright chest radiograph showing loops of colon in the thoracic cavity.
Computed tomography imaging of the thorax showing a large hiatal hernia containing essentially all the transverse colon (TC) which is distended with air fluid levels and thickening of its wall, indicating incarceration.
Coronal computed tomography imaging showing a large hiatal hernia with incarcerated transverse colon (TC). The colonic mesenterium (m) and a dilated cecum (C) are observed. Dilated stomach (S) due to gastric outlet obstruction is also observed.
Four types of hiatal hernias have been described (Table 1), with type IV being the least common. The combination of types II, III, and IV account for around 5% of all hiatal hernias, but type IV represents only 2–5% of those.1 Type IV are associated with a large defect in the phrenoesophageal membrane and abnormal laxity of the gastrosplenic and gastrocolic ligaments, which allows parts of the stomach and other intra-abdominal organs to enter the hernia sac.2,3 It is unknown if these predisposing abnormalities are acquired, congenital, or a combination of both.3 In our case, the defect allowed migration of, not only part of the stomach, but almost all the entire transverse colon into the hernia sac, causing ischemia and necrosis.
Types of Hiatal Hernias
Clinical manifestations of large hiatal hernias are unspecific, making their clinical diagnosis challenging. Symptoms vary from minimal epigastric discomfort and fullness to progressive dysphagia, chest discomfort, dyspnea, nausea, vomiting, and severe epigastric and chest pain.4 Their natural course can become complicated by volvulus, incarceration, perforation, or even recurrent pneumonia due to dysphagia and frequent vomiting with aspiration.5 As with our patient, incarceration or strangulation of the stomach and/or bowels may present as a life threating complication.5 If the large hiatal hernia is detected early in the course of the natural evolution, elective surgical repair is recommended, because emergent surgery has been associated with acute organ failure with poor outcomes and a reported mortality rate of up to 56% in some series.6,7 If left untreated, severe complications like outlet gastric obstruction, severe gastroesophageal reflux, and gastric or bowel strangulation may develop in up to 45% of patients in some reports (Table 1).6,8
Giant hiatal hernias are very infrequent, and their spectrum of clinical manifestations is large. Patients can present with minimal signs and symptoms or, as in this case, in extremis. The astute clinician must be aware of the existence of these oddities, including them in the differential diagnosis workup of patients with chest and/or upper abdominal pain, to implement in a timely manner the most appropriate intervention, which can range from only medical treatment to either elective surgical repair or emergent surgical correction.
- Received May 20, 2016.
- Accepted June 10, 2016.
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