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An 80 year old woman with intermittent severe vomiting

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Q1: What does the chest radiograph show?

The chest radiograph (see p 345) shows a large hiatus hernia extending behind the heart and into both lung fields.

Q2: What investigation is shown in fig 2 and what does it demonstrate? How does this relate to the presenting complaint?

Figure 2 (see p 345) is a single film from a barium meal series. The film demonstrates a partial rolling volvulus of the stomach. This is typically an intermittent phenomenon and when present results in profuse vomiting especially after eating.

Q3: How else can this condition present?

Small hiatus hernia rarely cause symptoms other than reflux which can usually be controlled medically, but giant hiatal hernias, where the majority of the stomach is intrathoracic as shown here, can present in a number of ways,1 including:

  • Severe reflux, retching, postprandial pain, bloating, and dysphagia due to mechanical pressure from the herniated stomach.

  • Haematemesis and iron deficiency anaemia from a “riding ulcer” formed by mechanical ulceration and mucosal ischaemia as the stomach passes through the diaphragm.2

  • Dyspnoea and aspiration pneumonia due to the loss of lung volume and high frequency of reflux with aspiration.

  • Severe epigastric or retrosternal pain with vomiting and fever are features of hernia strangulation.

Q4: How should this woman be managed?

Management of this condition is predominantly surgical. Until recently the decision to operate has been controversial, as patients are usually elderly and therefore the operative risks are high. However the condition responds poorly to conservative medical therapy and recent improvements in laparoscopic surgery techniques have led to an increase in the number of surgical procedures performed.3This woman underwent laparoscopic repair of her hernia with a successful outcome.

Discussion

Hiatal hernias occur commonly with some prevalence estimates suggesting that 15% of the population may be affected.1Most hernias are small and are either asymptomatic or associated solely with reflux. However, in a small proportion of hernias the diaphragmatic defect is large enough to allow the majority of the stomach to enter the thoracic cavity forming a “giant hiatus hernia” or intrathoracic stomach.1 Hiatal hernias are classified according to their mechanism of development into sliding, paraoesophageal, and mixed. Approximately 85% of hiatal hernias are of the sliding type with simple upward migration of the gastro-oesophageal junction into the mediastinum. Giant hiatal hernias have traditionally been thought to be of the paraoesophageal type, where part of the stomach passes through a defect in the diaphragm adjacent to the oesophagus. However recent evidence suggests that most hernias, regardless of size, originate as the sliding type.4 It is postulated that a “giant hiatus hernia” forms when an existing sliding hernia exerts pressure on tissue around the diaphragm resulting in weakness, which ultimately allows the stomach to pass into the thorax alongside the original sliding hernia, thus forming a mixed hernia.

Giant hiatal hernias occur almost exclusively in the elderly and are associated with a number of presentations including postprandial chest pain, symptomatic reflux, dysphagia, vomiting, haematemesis, iron deficient anaemia, dyspnoea caused by lung displacement, and aspiration pneumonia.1 4 Strangulation may occur following gastric volvulus and is suggested by severe chest and epigastric pain associated with persistent vomiting. The rate of occurrence of strangulation is controversial but an early series showed six cases in 21 patients with giant hiatal hernias treated conservatively.5 Physical signs are rarely helpful in making the diagnosis, although bowel sounds may be heard high in the chest and basal breath sounds can be reduced due to upward displacement of the lungs.1 A chest radiograph may show the stomach as an extramediastinal shadow or there may be an air fluid level behind the heart. Diagnosis is usually confirmed by barium swallow or with fibreoptic endoscopy.

Surgery is thought to be the best management option, as medical therapy does not alter the risk of strangulation or resolve the mechanical displacement of the stomach that accounts for many of the symptoms.1 4 Despite these benefits surgery had been controversial as many patients were elderly, but the introduction of laparoscopy has revolutionised the treatment of giant hiatal hernias and has resulted in an increased number of procedures being performed.3

Final diagnosis

Giant intrathoracic hiatus hernia.

References

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