PARAESOPHAGEAL HERNIA RESULTING IN INTRATHORACIC VOLVULUS

Abstract

Introduction: Paraesophageal hernias are a rare form of hiatal hernias which can be potentially life threatening because of the risk of volvulus and incarceration. We report a patient who was found to have a massive, incarcerated paraesophageal hernia with gastric volvulus. Case Report: An 83-year-old male with a history of emphysema, coronary artery disease with bypass and hiatal hernia presented with severe chest pain extending from the sternum to the back, dyspnea and vomiting. The patient developed respiratory failure requiring intubation. On physical exam the abdomen was distended and firm. Initial chest radiograph demonstrated a large, cyst-like mass and an air-fluid interface in the thorax suggesting an emphysematous bullae. A catscan (CT) of the chest, abdomen and pelvis showed a large paraesophageal hernia with a dilated stomach occupying the majority of the right hemithorax with shifting of the heart. Dilated loops of small bowel and proximal colon with air fluid levels were also noted. The patient underwent an urgent laparotomy, which revealed an intrathoracic gastric volvulus. The surgery included a partial gastrec-tomy and repair of the anatomical defects responsible forthe paraesophageal hernia. Discussion: Paraesophageal hernia, a condition in which the fundus and part of the body of the stomach wrapped in a peritoneal sac herniate into the mediastinum, is a relatively uncommon entity. Acute presentations of paraesophageal hernias require emergent surgical intervention, presenting a risk of catastrophic complications including excessive bleeding or volvulus with acute gastric infarction. The classical presentation of acute gastric volvulus is Borchardt's triad of severe abdominal pain, violent retching, and inability to pass a nasogastric tube. Delay in diagnosis and treatment of gastric volvulus can lead to fatal complications such as gastric ischemia, perforation, and hemorrhage. Gastric volvulus is a true emergency and should be treated immediately either surgically or by temporary endoscopic reduction. Intrathoracic volvulus is an uncommon entity and even with surgical intervention carries a high mortality.