ATYPICAL CHEST PAIN MAKES A SLIDING COME-UP INTO THE DIFFERENTIAL

Abstract

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: There are approximately 7.6 million annual visits for chest pain, making it the second highest cause for Emergency Department visits in the United States.1 A differential that is rarely considered yet possesses a high occurrence rate in the United States is hiatal hernia. Greater than 95% of hiatus hernias are sliding type I, while the prevalence of paraesophageal type II, type III, and IV hernias make up less than 5% of the cases.2 CASE PRESENTATION: 79-year-old female presented to the emergency department (ED) with a chief complaint of acute, 8/10 sharp chest pain that radiated to the midthoracic spine for a few hours before presentation. Associated symptoms included progressive dyspnea over the past few months. Her medical history was remarkable for diabetes mellitus type 2 and peripheral vascular disease. In the ED, patient was afebrile, pulse 106 bpm, respiration rate 31 bpm, blood pressure of 166/95 mm Hg, and pulse oximetry of 96% on room air. Pulmonary computed tomography angiogram (Figure 1A and B) showed a large left hiatal hernia containing the stomach and portions of the transverse colon and fat. Esophagogastroduodenoscopy (EGD) was performed which confirmed a large paraesophageal hernia with more than 75% of the stomach herniated and volvulized with incarceration in the chest, along with first part of the colon. The patient underwent successful laparoscopic repair of the hernia with esophageal mediastinal mobilization and gastropexy. The patient’s dyspnea and chest pain resolved over the following 3 post-operative weeks. DISCUSSION: The majority of patients with hiatal hernias are asymptomatic and are found incidentally on imaging. The only method of confirming a diagnosis of a hiatal hernia is with upper endoscopy or barium swallow. Both gastroesophageal reflux diseases (GERD) and obesity are risk factors that contribute to the development of a hiatal hernia. Studies show 50-94% of patients with GERD have a type 1 hiatal hernia as compared to 13-59% of normal.2 The result of delayed diagnosis increases the risk of complications such as gastric volvulus, gastric distension, gastric bleeding, erosions, or gastritis within the herniated pouch. Respiratory complications via mechanical compression of the lungs from the hernia or other organs herniating upwards is also frequently seen in large hernias.3 CONCLUSIONS: In summary, the consideration for hiatal hernias in patients presenting with chest pain should be especially heightened in the United States due to high rates of GERD and obesity. This case demonstrates chest pain as an uncommon chief complaint in patients with hiatal hernias and should be kept in the differential diagnosis of emergency and internal medicine physicians. Reference #1: 1.Rui P, Kang K, Ashman JJ. National Hospital Ambulatory Medical Care Survey: 2016 emergency department summary tables. 2016. Reference #2: 1.Wright, RA, Hurwitz, AL. Relationships of Hiatal Hernia to Endoscopically Proved Reflux Esophagitis. Dig Dis Sci 1979 Apr;24(4):311-3. Reference #3: 1.Weston, AP. Hiatal Hernia with Cameron Ulcers and Erosions. Gastrointest Endosc Clin N Am. 1996 Oct;6(4):671-9. DISCLOSURES: No relevant relationships by Katherine Fu, source=Web Response No relevant relationships by Dean Helseth, source=Web Response No relevant relationships by Israel Ugalde, source=Web Response