Abstract
A 93-year-old female presented with persistent shortness of breath and wheezing since the consumption of a meal. Her past medical history is significant for a clinical diagnosis of asthma at the age of 88 years, without pulmonary function testing, complicated by several prior visits to the emergency department (ED) for recurrent exacerbations. Multiple bronchodilators in the ED provided only minimal improvement in her symptoms. Chest imaging eventually revealed a giant, fluid-filled hiatal hernia exhibiting a compressive effect on the posterior aspect of the left atrium. The etiology of the patient's airway bronchoconstriction was likely multifactorial. We hypothesize that the extrinsic, dynamic compression of the bronchial tree by the peristaltic motion of the hiatal hernia, microaspiration from gastroesophageal reflux, and peribronchial edema from left atrial compression accounted for our patient's unique presentation. An outpatient methacholine challenge test eventually excluded bronchial asthma. Although she was considered a poor surgical candidate, she has had no further recurrences of her symptoms with counseling on conservative lifestyle changes. This case serves to highlight the heterogeneity in presentations of hiatal hernias, particularly in elderly females. Furthermore, it remains prudent to maintain a broad differential for wheezing, as evidenced by our patient who was previously managed for a number of years as poorly controlled asthma.
Highlights
A giant hiatal hernia presents a diagnostic and therapeutic dilemma for most clinicians, often being found incidentally on chest imaging
We present a unique case of a patient with a giant hiatal hernia who was being managed for a number of years as poorly controlled asthma, along with a brief review of the literature
Her past medical history is significant for hypertension, osteoarthritis, and a clinical diagnosis of bronchial asthma at the age of 88 years, without prior pulmonary function testing
Summary
A giant hiatal hernia presents a diagnostic and therapeutic dilemma for most clinicians, often being found incidentally on chest imaging. A 93-year-old female presented to the emergency department with persistent shortness of breath and wheezing since consumption of a meal Her past medical history is significant for hypertension, osteoarthritis, and a clinical diagnosis of bronchial asthma at the age of 88 years, without prior pulmonary function testing. Due to persistent tachycardia and initial presentation of hypoxia, there was a concern for a pulmonary embolism, so a computed tomography pulmonary angiogram study (CTPA) was ordered and no emboli were found It did reveal right ventricular enlargement and most notably, a distended, fluid-filled giant hiatal hernia exerting extrinsic mass effect on the posterior aspect of her heart, the left atrium (Figures 2-5). On outpatient follow-up, she reported a significant improvement in her symptoms and has since had no further episodes of wheezing following the establishment of her lifestyle changes
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
