Inchworm Hiatal Hernia Causing Recurrent Abdominal Pain and Gastrointestinal Bleeding: 2017 Presidential Poster Award

Abstract

Hiatal hernias, including paraesophageal hernias (PEHs), are frequently encountered in clinical practice, and surgical repair remains the standard of care for large and/or symptomatic lesions. Unfortunately, anatomic recurrence is not uncommon and rare complications exist. A 78-year-old woman with a history of PEH status post-laparoscopic repair with mesh and partial fundoplication presented to a regional hospital with recurrent melena. She had recently been hospitalized with abdominal pain and gastrointestinal bleeding that had resolved without intervention. On admission, her physical exam was remarkable for melena in the rectal vault. Her abdomen was soft and non-tender, but her hemoglobin had dropped 2 points over the preceding 48 hours. EGD revealed a loose fundoplication and a hiatal hernia involving the middle segment of the gastric body. Erosive gastritis was seen at areas traversing the diaphragm with tissue friability and evidence of recent bleeding. Endoscopic evaluation was challenging due to the fact that openings to concatenated gastric segments could only be viewed and accessed in a retroflexed position (Figure 1). Recently acquired cross-sectional imaging was remarkable for a recurrent, type IV hiatal hernia in which the middle section of the gastric cavity was herniated through the diaphragm, forming an “inchworm” stomach (Figures 2, 3). Trauma from sliding and other mechanical forces caused Cameron's gastric erosions, abdominal pain, and recurrent bleeding. The patient's bleeding was managed conservatively, and she was referred to gastrointestinal surgery for definitive management. Although anatomic recurrence after surgical repair of PEH is common, the patient's “inchworm” hiatal hernia is unique. As such, this case represents an uncommon etiology for common symptoms: recurrent abdominal pain and gastrointestinal bleeding. While the focus of the endoscopist is often limited to intraluminal pathology, a complete understanding of the patient's anatomy is necessary to identify the true etiology of a gastrointestinal bleed.Figure: Endoscopic image demonstrating herniated segment of gastric body. The arrow points to the opening to the subdiaphragmatic antrum and duodenum.Figure: Coronal (A), transverse (B), and sagittal (C) sections of patient's type IV hiatal hernia on computed tomography.Figure: Illustration of the patient's “inchworm” hiatal hernia.