Acute Ischemic Colitis Caused by Transhiatal Herniation and Incarceration of the Stomach and Transverse Colon

Abstract

Purpose: An 89-year-old woman with a long-standing history of para-esophageal hiatal hernia was hospitalized with one-day duration of severe nausea, vomiting and abdominal pain, and multiple episodes of red blood per rectum. Physical examination showed diffuse abdominal tenderness worse in the left upper and lower quadrants. Laboratory data showed: hemoglobin 8.6 g/dl dL (range: 12-14), WBC 19.9 K/cu cmm (range: 4.7-11), platelet 208 K/cmm (range: 150-450) and lactate 3.8 mmol/L (range: 0.5-2.2). Computed tomography showed a large para-esophageal hernia and organo-axial volvulus of an entirely intrathoracic stomach. The herniated sac also contained portions of the transverse and left colon. Diffuse wall thickening involving the distal transverse colon, left colon and sigmoid colon and peri-colonic stranding were noted with a transition point at the hernia. This was most consistent with ischemic colitis due to transhiatal herniation and incarceration of the colon. The patient was treated with nil per os, nasogastric suction and antibiotics. An urgent surgical correction of the volvulus and hernia was planned; however, the patient opted for palliative care and declined surgery. A repeat CT in 24 hours showed spontaneous resolution of the gastric volvulus and colonic herniation. The patient remained hospitalized for three weeks and required parenteral nutrition as well as several blood transfusions because of severe rectal bleeding. Fortunately, she made a complete recovery. Transhiatal herniation and incarceration of the stomach and colon are rare and potentially life threatening complications of para-esophageal hernias. Early surgical intervention of large hernias may prevent a later catastrophe.Figure: CT abdomen showing colonic incarceration at hiatal hernia and wall thickening of distal colon (arrow).Figure: CT chest showing organoaxial volvulus of intrathoracic stomach.