An Unusual Diaphragmatic Hernia

Abstract

Question: A previously healthy 39-year-old man presented to our hospital with a 1-week history of epigastric pain, nausea, and vomiting. He had no concomitant medical condition. His past medical history was unremarkable. He had no previous surgery or thoracoabdominal trauma history. The routine work-up on admission was normal. An immediate chest radiograph demonstrated the air–fluid level that projected above the diaphragm, to the far left of the midline (Figure A). The upper gastrointestinal (GI) series showed the esophagogastric unction was in the normal position, but the contrast medium would not pass through the mid-stomach (Figure B). The contour and orientation of the stomach by upper GI series and endoscopy suggested a mesenteroaxial gastric volvulus with herniation of the gastric body into the thorax (Figure C). Subsequent computed tomography of the chest and abdomen showed a diaphragmatic hernia containing he transverse colon as well as a significant portion of the posterior gastric body (Figure D). He elected to undergo a laparoscopic operation. he intraoperative finding is shown in Figure E (1, lower esophagus; 2, left paraesophageal space; 3, intervening muscle band; 4, left iaphragmatic crus; 5, lower lobe of the left lung through the defect). What is the diagnosis? Look on page 1623 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information n submitting your favorite image to Clinical Challenges and Images in GI.