Chest Pain of Atypical Etiology: A Type IV Paraesophageal Hernia

Abstract

A 59-year-old man with a history of coronary artery disease presented to the emergency department with chest “heaviness,” comparable with his prior myocardial infarction, and a “mass” sensation in his chest while denying any gastrointestinal symptoms. He was tachypneic to a rate of 28 breaths per minute but hemodynamically stable. His electrocardiogram was unchanged from prior studies and laboratory data were unremarkable. An anteroposterior chest radiograph (Figure A) demonstrated a large retrocardiac hiatal hernia with a visible air fluid level (white arrows). Follow-up computed tomography angiography of the chest, abdomen, and pelvis revealed the entirety of the stomach (yellow arrows) and most of the transverse colon (red arrows) within the mediastinum appreciable in sagittal (Figure B), coronal (Figure C), and transverse (Figure D) views. Given the inclusion of extragastric abdominal viscera within the hernia, it was classified as type IV paraesophageal hernia (types I-III are delineated by varying involvement of the esophagus and gastric fundus). Predisposing risk factors include a large defect in the phrenoesophageal membrane, and an increased laxity in the esophageal hiatus. Postdischarge, an upper gastrointestinal series was obtained illustrating organoaxial volvulus and the patient is now being evaluated for laparoscopic bowel reduction and diaphragmatic repair to preempt the risk of incarceration, strangulation, perforation, bleeding, or respiratory compromise.