Paraesophageal Paradigm: An Unusual Cause of Dyspnea

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Clinicians commonly encounter complaints of cough, dysphagia, and dyspnea. We report a rare etiology of these symptoms, a large paraesophageal hernia with an organoaxial volvulus. A 68 year-old male with hypertension, reflux disease, obesity, and smoking history presented with cough, dysphagia, and progressive dyspnea. His physical exam and routine laboratory studies were within normal limits. Despite maximum dose proton pump inhibitor (PPI) therapy, his symptoms progressed. The patient was referred to gastroenterology for esophagoduodenoscopy (EGD) evaluation of his dysphagia. On EGD a large hiatal hernia, possibly a paraesophageal hernia, was seen. Based on this finding, an upper gastrointestinal (UGI) series using barium was performed and revealed a “very large hiatal hernia containing all of the stomach and a portion of the left colon.” Additionally, the report noted an organoaxial volvulus of the stomach with the stomach rotated along its long axis with the greater curvature above the gastroesophageal junction (GEJ) in the superior portion of the hernia sac. A computed tomography (CT) scan of his chest confirmed the UGI findings. The patient was referred to surgery for repair of this large symptomatic hernia. The stomach can herniate above the diaphragm into the thoracic cavity via a hiatal hernia, of which there is a sliding-type (I) and paraesophageal types (II-IV). This patient likely had a type II hernia initially, but gradual expansion over time led to involvement of the GEJ and the left colon, classifying it as type IV hernia. When hernias enlarge, the stomach can rotate, creating a volvulus that can potentially lead to obstruction and ischemic changes in the stomach. A mesenteroaxial volvulus occurs with stomach rotation along its transverse short axis, displacing the pyloric antrum superior to the GEJ. Organoaxial volvulus involves rotation along the stomach's long axis, displacing the greater curvature superiorly and lesser curvature inferiorly. Paraesophageal hernias present more frequently with complications such as a gastric volvulus. Definitive treatment involves surgical repair of the hernia with reduction of the gastric volvulus. This case highlights a rare diagnosis of a large paraesophageal hernia with an organoaxial volvulus that presented with the common complaints of dyspnea and dysphagia. After an EGD pointed to suspicion of a paraesophageal hernia, follow up imaging led to a definitive diagnosis.Figure: CT image showing gastric volvulus in hernia sac.Figure: CT image showing colon in the hernia sac.