A Case of Massive Hematemesis from a Paraesophageal Hernia Containing Stomach, Bowel, and Pancreas

Abstract

A paraesophageal hernia is characterized by dislocation of the gastric fundus superiorly. They account for about 5% of all hiatal hernias. Majority are asymptomatic, some can be associated with intermittent GERD. Severe complications include gastric volvulus, gastric outlet obstruction, and hemorrhage. We present a case of a large paraesophageal hernia presenting with severe hemorrhage.Figure 1Figure 2Figure 354 year old man with polycythemia vera complicated by recurrent venous thromboembolism presents to the ER with 12 hours of painless hematemesis without wretching. His medications include enoxaparin, aspirin, and ibuprofen for tension headaches. He had no history of GERD or peptic ulcer disease, but had an episode of persistent vomiting 4 years ago in which EGD showed gastric volvulus. Surgery was deferred at that time due to medical comorbidities. On exam, heart rate was 123, blood pressure was 139/97, and abdominal exam was benign. He was admitted to the medical ICU and treated with pantoprazole IV drip. Emergent EGD revealed a large paraesophageal hernia with hematin and food debris in the stomach limiting visualization. EGD was repeated the following day, demonstrating 2 distinct superficial ulcers in the paraesophageal hernia sac, one with adherent clot, no evidence of Cameron lesions, and LA Grade D esophagitis. Four hemostatic clips were placed on the ulcers that presumably were culprits for bleeding. CT showed the hernia contained the entirety of the stomach, a large portion of the transverse colon, and small portions of the pancreas and small bowel mesentery. There was stable rotation of the stomach with organoaxial twisting. The patient's bleeding stabilized and he was discharged with outpatient surgical appointment, however he was lost to follow-up. In the case reported, the patient's hemorrhage was caused by 2 ulcers in the paraesophageal hernia sac and was managed without surgical intervention. NSAID use likely contributed to the development of the ulcers with concomitant enoxaparin use contributing to acute hematemesis. Etiology of hiatal hernias is usually speculative but may include trauma and congenital malformation. Treatment for paraesophageal hernias is surgical. In complicated type IV hiatal hernias the majority of patients can be safely treated conservatively in the acute setting, with elective surgery scheduled later. Still, the management is controversial. In this case, the patient chose to continue enoxaparin and hold off surgery.