Abstract
BackgroundWith an incidence of less than 5%, type II paraesophageal hernias are one of the less common types of hiatal hernias. We report a case of a perforated prepyloric gastric ulcer which, due to a type II hiatus hernia, drained into the mediastinum.Case presentationA 61-year old Caucasian man presented with acute abdominal pain. On a conventional x-ray of the chest a large mediastinal air-fluid collection and free intra-abdominal air was seen. Additional computed tomography revealed a large intra-thoracic air-fluid collection with a type II paraesophageal hernia. An emergency upper midline laparotomy was performed and a perforated pre-pyloric gastric ulcer was treated with an omental patch repair. The patient fully recovered after 10 days and continues to do well.ConclusionType II paraesophageal hernia is an uncommon diagnosis. The main risk is gastric volvulus and possible gastric torsion. Intrathoracic perforation of gastric ulcers due to a type II hiatus hernia is extremely rare and can be a diagnostic and treatment challenge.
Highlights
A 61-year old Caucasian man with a previous medical history of a peptic ulcer, which was treated with a proton pomp inhibitor (PPI) and H. pylori eradication, presented with acute abdominal pain after several days of extensive vomiting and abdominal discomfort
On the left-side of this mass the esophagus is seen with a nasogastric tube (2) indicating a rightsided para-esophageal hernia with free intra peritoneal air and fluid
With an incidence of less than 5%, type II paraesophageal hernias are one of the less common types of hiatal hernias
Summary
Type II paraesophageal hernia is an uncommon diagnosis. The main risk is gastric volvulus and possible gastric torsion. On a conventional x-ray of the chest (Figure 1) a large mediastinal air-fluid collection and the suspicion of free intra-abdominal air, suggestive of a hiatal hernia and intra-abdominal perforation, was seen. Additional computed tomography (CT) (Figure 2 and 3) revealed the aforementioned intra-abdominal free air and a large intra-thoracic air-fluid collection with a type II paraesophagal hernia. On the left-side of this mass the esophagus is seen with a nasogastric tube (2) indicating a rightsided para-esophageal hernia with free intra peritoneal air and fluid. Axial 5 mm CT-slice after i.v. contrast admission This slice shows an intra-abdominal situated stomach with nasogastric tube (1); esophagus with NGT (2); right-sided para-esophageal hernia with intraperitoneal fat (a), free-fluid (b) en free-air (c) (3); intra-peritoneal free-air (4)
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