Abstract
IntroductionPatients with paraesophageal hernias often present secondary to chronic symptomatology. Infrequently, acute intestinal ischemia and perforation can occur as a consequence of paraesophageal hernias with potentially dire consequences. Case presentationAn 86-year-old obtunded male presented to the emergency department with hypotension and severe back and abdominal pain. An emergency abdominal CT scan was ordered with a presumptive diagnosis of ruptured abdominal aortic aneurysm. CT topograms revealed extensive free intra-abdominal air and herniated abdominal viscera into the right hemithorax. Prior to completion of the CT study, the patient sustained a cardiopulmonary arrest. Surgery was consulted, but the patient was unable to be revived. Post-mortem examination revealed gross contamination within the abdomen and a giant, incarcerated, hiatal hernia with organoaxial volvulus and ischemic perforation.ConclusionCurrent recommendations call for prompt repair of giant hiatal hernias before they become symptomatic due to the increased risk of strangulation. Torsion of the stomach in large hiatal hernias frequently leads to a fatal complication such as this warranting elective repair as soon as possible.
Highlights
Patients with paraesophageal hernias often present secondary to chronic symptomatology
Current recommendations call for prompt repair of giant hiatal hernias before they become symptomatic due to the increased risk of strangulation
Torsion of the stomach in large hiatal hernias frequently leads to a fatal complication such as this warranting elective repair as soon as possible
Summary
Torsion of the stomach in these very large hiatal hernias can lead to fatal complications with considerable frequency, and as a result, elective repair is warranted upon discovery except in the moribund patient [2]. Collis-Nissen fundoplication may be added to the repair to accommodate relative esophageal shortening but not without risk of dysmotility of the distal esophagus [5]. While traditionally these repairs were approached via celiotomy or thoracotomy, the majority of cases are amenable to laparoscopic approaches with excellent outcomes [6]. AS, EZ and SA were involved in the literature review and obtaining the critical intellectual content used in this case report. These three authors have given final approval for publication
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