SESSION TITLE: Surgery Case Report Posters I
SESSION TYPE: Case Report Poster
PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM
INTRODUCTION: Incidence of hiatal hernias (HH) increases with age. Approximately 60% of individuals aged 50 or older have a HH.  A giant HH is a hernia that includes at least 30% of the stomach in the chest, although a uniform definition does not exist; most commonly, a giant HH is a type III hernia with a sliding and paraesophageal component . Patients with a giant HH generally present with pain, heartburn or a history of heartburn, dysphagia, vomiting, and anemia. We present a case of giant HH presenting with hematemesis.
CASE PRESENTATION: An 83-year-old non-smoking female patient, with breast cancer who underwent breast biopsy and sentinel node dissection 2 days prior, presented to her local hospital with severe lower chest discomfort, nausea and vomiting with episodes of hematemesis. Initial workup with chest x-ray revealed a giant chest abnormality (figure 1). Further review of imaging revealed a giant paraesophageal hiatal hernia with most of her stomach residing in the chest. The stomach was massively dilated and appeared volvulized. She had an endoscopy and a liter of fluid was drained from her stomach. A nasogastric tube was placed. However, the stomach remained massively dilated and did not appear to be emptying. She was transferred for further care. Upon transfer, the patient was on a 100% nonrebreather due to difficulty breathing. Her pain and nausea had improved; however, she remained dyspneic. She had mild tenderness in the epigastrium and her white count was elevated at 18,000. She was taken to the operating room by cardiothoracic surgery urgently for reduction of her giant paraesophageal hiatal hernia. Post op chest x-ray revealed impressive improvement (figure 2). On the date of discharge, she was satting 93% on room air. Pathology of the hernia sac revealed mesothelial lined fibrous tissue consistent with hernia sac.
DISCUSSION: HH is the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. A HH is classified by type as follows: type I indicates sliding hernia; type II, paraesophageal hernia ( 5%); type III, mixed sliding and paraesophageal hernia; and type IV, herniation of additional organs (eg, colon, omentum, spleen).  A giant HH is a hernia that includes at least 30% of the stomach in the chest and most commonly is a type III hernia with a sliding and paraesophageal component. This case illustrates the varied presentations of giant HH and the need for early suspicion given the need for surgical intervention.
CONCLUSIONS: This case illustrates the need to consider giant HH in the presence of hematemesis. Early recognition of this rare entity can lead to early surgical intervention.
Reference #1: Goyal Raj K, "Chapter 286. Diseases of the Esophagus". Harrison's Principles of Internal Medicine, 17e.
Reference #2: Mitiek, MO “Giant Hiatal Hernia” Annl Thor Surg 2010 Jun;89(6):S2168-73.
Reference #3: Landreneau RJ et al. Management of paraesophageal hernias Surg Clin North Am 2005;85:411-432
DISCLOSURE: The following authors have nothing to disclose: Anita Rajagopal, Anthony Ascioti
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