Paraesophageal Hernia With Gastric Herniation Complicated by Tracheal and Bronchial Compression

Abstract

The gastroesophageal junction (GEJ) is anchored by the phrenoesophageal ligament surrounding the esophageal hiatus of the diaphragm. With each contraction of the longitudinal muscles, the GEJ and the gastric cardia are proximally displaced through the phrenoesophageal membrane, and brought back by the elastic recoil of the membrane. When the integrity of the elastic membrane is compromised, abdominal contents herniate into the posterior mediastinum, known as paraesophageal hernias (PEH). Type I hernia, which constitutes 95% of cases, causes migration of the GEJ and the proximal gastric cardia above the esophageal hiatus into the thoracic cavity. Types II-IV are 5% of cases. Types IV include herniation of the GEJ along with the gastric fundus along with other organs. We present a case of paraesophageal hernia complicated by tracheal and bronchial compression. 84-year-old female presented with worsening shortness of breath associated with midsternal chest pain radiating to the epigastric region with nasusea and vomiting. Past medical history includes chronic volvulus of the stomach, congestive heart failure, hypertension. Physical exam revealed decreased breath sounds on bilateral lower lung fields & +2 bilateral lower extremity edema. Labs were unremarkable. Abdominal x-ray performed were equivocal. CT pulmonary angiogram found luminal narrowing of the trachea & total herniation of stomach with fat & the tail of the pancreas in to the chest. No surgical intervention was reccomended, & was treated by pantoprazole. On follow up, symptoms had improved. PEHs can be challenging due to their low incidence & limited literature along with non-specific symptoms. Patients with type IV hernias may have symptoms of dysphagia, epigastric pain, dyspnea, nausea, chest pain, & iron deficiency anemia due to cameron lesions. Rarely, the herniated stomach can rotate around its longitudinal axis resulting in volvulus in the intrathoracic cavity. Barium swallow is the most sensitive diagnostic test but CT/MRI reveals retrocardaic air-fluid levels within the hernia sac. Surgical repair is indicated in patients with symptomatic PEH but management in asymptomatic patients is controversial. In patients with gastric volvulus, obstruction, strangulation, perforation and respiratory compromise should be evaluated for repair. Our case is unique in that the pancreas is rarely involved in a Type IV hernia, which usually requires surgical intervention.