S2918 Giant Paraesophageal Hernia and Gastric Volvulus: An Uncommon Etiology of Vomiting and Upper Gastrointestinal Bleeding

Abstract

INTRODUCTION: Paraesophageal hiatal hernia is a rare type of hiatal hernia, which occurs mostly in the elderly population after the age of 70, and accounts for less than 5% of all hiatal hernias. Here we report a rare case of a large paraesophageal hiatal hernia and gastric volvulus as an uncommon cause of vomiting and upper gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 46-year-old female with a past medical history of anemia and GERD presents with one day history of coffee ground emesis and melena. She has no history of previous gastrointestinal bleeding and denies NSAID use. She has been off PPI agents for one year due to the improvement of acid reflux disease after weight loss of 40 lbs. Etiology of anemia was not found during the previous GI workup including an upper endoscopy completed locally. Upon presentation, her hemoglobin was checked low at 9.3 g/dl from her baseline of 11.0 g/dl. She underwent a repeat upper endoscopy which revealed a large paraesophageal hernia (7 cm) with multiple linear erosions/ulcerations, suggestive of Cameron's lesions. The insufflation of the stomach was abnormal, with a distorted antrum located at an eccentric angle concerning for gastric volvulus. Further workup with computerized tomography (CT) scan of the chest and abdomen showed findings of a large type 3 hiatal hernia with organoaxial volvulus, and no evidence of ischemia or obstruction. She subsequently underwent laparoscopic repair of her paraesophageal hernia and Nissen fundoplication with resolution of anemia after the surgery. DISCUSSION: Paraesophageal hernia with gastric volvulus is a rare entity that can manifest with vomiting due to partial or complete gastric outlet obstruction, and gastrointestinal bleeding due to mucosal ischemia or Cameron's lesions. It is critical for gastroenterologists to recognize paraesophageal hiatal hernias during upper endoscopy evaluation, due to its association with gastric volvulus leading to incarceration and life-threatening strangulation. Emergency surgery is required for acute ischemic gastric volvulus. Otherwise, elective surgery can be offered to symptomatic patients and laparoscopic surgery is the mainstay of treatment approaches.Figure 1.: Giant Paraesophageal hiatal hernia: Retroflexion (A) and forward view (B) revealed giant hiatal hernia with Cameron lesions. C: Chest/abdominal CT confirmed large type 3 paraesophageal hernia with gastric volvulus.