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Abstract

Introduction: INTRO: Incidence of hiatal hernias (HH) increases with age. Approximately 60% of individuals aged 50 or older have a HH. [1] A giant HH is a hernia that includes at least 30% of the stomach in the chest, although a uniform definition does not exist; most commonly, a giant HH is a type III hernia with a sliding and paraesophageal component [2]. Patients with a giant HH generally present with pain, heartburn or a history of heartburn, dysphagia, vomiting, and anemia. We present a case of giant HH presenting with hematemesis. Case: An 83-year-old non-smoking female patient, with breast cancer who underwent breast biopsy and sentinel node dissection 2 days prior, presented to her local hospital with severe lower chest discomfort, nausea and vomiting with episodes of hematemesis. Initial workup with chest x-ray revealed a giant chest abnormality (figure 1). Pulmonary was consulted to evaluate the giant chest mass. Further review of imaging revealed a giant paraesophageal hiatal hernia with most of her stomach residing in the chest. The stomach was massively dilated and appeared volvulized. She had endoscopy at an outside facility and they drained a liter of fluid from her stomach. A nasogastric tube was placed. However, the stomach remained massively dilated and did not appear to be emptying. She was transferred for further care. Upon transfer, the patient was on a 100% nonrebreather due to difficulty breathing. Her pain and nausea had improved; however, she remained dyspneic. She had mild tenderness in the epigastrium and her white count was elevated at 18,000. She was taken to the operating room by cardiothoracic surgery urgently for reduction of her giant paraesophageal hiatal hernia. On the date of discharge, she was satting 93% on room air. Pathology of the hernia sac revealed mesothelial lined fibrous tissue consistent with hernia sac. Discussion: HH is the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. A HH is classified by type as follows: type I indicates sliding hernia; type II, paraesophageal hernia ( 5%); type III, mixed sliding and paraesophageal hernia; and type IV, herniation of additional organs (eg, colon, omentum, spleen). [3] A giant HH is a hernia that includes at least 30% of the stomach in the chest and most commonly is a type III hernia with a sliding and paraesophageal component. This case illustrates the varied presentations of giant HH and the need for early suspicion given the need for surgical intervention. Conclusion: This case illustrates the need to consider giant HH in the presence of hematemesis. Early recognition of this rare entity can lead to early surgical intervention.