Hematemesis Secondary to Paraesophageal Hernia With Incarcerated Gastric Volvulus

Abstract

Introduction: Paraesophageal hernias are uncommon and typically occur in the elderly. Most cases are asymptomatic, but can present with dyspepsia or respiratory distress. Acute complications like incarcerated gastric volvulus are rare, but can be life threatening. Case Report: A 46 year-old male presented with dysphagia and 10 lb weight loss for 3 months and hematemesis for 3 days prior to presentation. He denied chest pain, dyspepsia, shortness of breath, melena or hematochezia. Past medical history included hypertension and chronic hepatitis C infection. He denied NSAID use or family history of gastric or esophageal cancer. Abdominal exam was benign. Laboratory values were significant for leukocytosis and elevated aspartate aminotransferase. A nasogastric tube was placed and aspirated 200 cc of dark red blood. Vital signs were stable with hemoglobin unchanged from previous labwork. Attempts at upper endoscopy showed dilated esophagus, dark blood in the proximal esophagus, and large, hemorrhagic, ball-valve like mass in the distal esophagus which precluded further evaluation. Thoracoabdominal computed tomography revealed a soft tissue mass in the mediastinum comprised of duodenum, pylorus, and antrum and hypoenhancement of the stomach wall concerning for vascular compromise. Emergency exploratory laparotomy identified an incarcerated paraesophageal hernia with mesenteroaxial gastric volvulus, hyperemic gastric wall with focal polypoidal lesion along the greater curvature. Paraesophageal hernia repair with gastropexy and wedge resection of the lesion were performed. Histopathology showed diffuse coagulative necrosis with no malignancy. The patient had an uncomplicated post-operative course and on follow up reported baseline functional status with no recurrence of symptoms. Discussion: Paraesophageal hernias typically present in the geriatric population and can present with nonspecific symptoms. Less than 5 cases presenting with hematemesis have been reported and none in adults. In the presented case, a middle-aged adult presenting with hematemesis was found to have a paraesophageal hernia and secondary gastric volvulus complicated by gastric ischemia and necrosis. Prompt recognition of this emergent condition and subsequent surgical intervention are crucial for preventing further complications.Figure 1