A Woman With Increasing Dypsnea

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• Answer to the Clinical Challenges and Images in GI Question: Image 2: Giant Hiatal Hernia With Migration to the Thorax of the Whole Stomach and Part of the Duodenum
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Question: A 78-year-old woman was referred to our Gastroenterology unit because of deteriorating chronic reflux symptoms and increasing dyspnea. She had a long clinical history of mild pyrosis and regurgitation. In fact, after an esophagogram, the diagnosis given by her family physician was a hiatal hernia from which he had been suffering for a considerable time. Reflux symptoms were worse by night. After a complete interview, although she had been referred to our unit because of the worsening condition of her mild chronic reflux symptoms, she recognized that her main clinical complaint was her increasing dyspnea, which had been more severe in the previous 6 months.

Three years before the current presentation, she had suffered 1 episode of mild aspiration pneumonia, which improved with antibiotic therapy. After discharge from hospital, she had her bed headboard elevated, and was compliant with basic dietetic measures, following advice given by her family physician. In fact, she had a good control of nocturnal symptoms and complications. Other clinical problems were severe hypertension and insomnia. Otherwise, she enjoyed good health, and was able to lead a relatively independent life.

Physical examination showed a lean patient, with a complete absence of breath sounds in the left thorax. Cardiac tones were normal. The abdominal examination proved normal and baseline oxygen saturation was 92%. Routine blood test showed minor abnormalities (neither anemia nor any other major abnormalities were found, other than mid hypercholesterolemia and hypertriglyceridemia). An ECG showed a right cardiac axis deviation. A thoracic radiograph taken 2 years earlier was considered normal by her family doctor.

When an upper endoscopy was offered she refused the procedure, but accepted upper gastrointestinal series. Computed tomography (CT) was also performed (Figures A and B). What was the diagnosis?

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Answer to the Clinical Challenges and Images in GI Question: Image 2: Giant Hiatal Hernia With Migration to the Thorax of the Whole Stomach and Part of the Duodenum 

As shown in Figure B, the barium esophagogram showed a complete passage of the stomach to the thoracic cavity. It was inverted, with the cardia located near the hiatus, and the duodenal bulb was in the upper position. The second duodenal portion passed through the hiatus to the abdominal cavity (Figure C). The CT scan confirmed migration of the stomach and duodenum to the left thorax, with a massive atelectasia of the left lung. The spleen and left kidney were in their usual location (Figure D).

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Paraesophageal and giant mixed hiatal hernias are rarely asymptomatic. It has been estimated that around 50% of patients have gastroesophageal reflux, and other symptoms such as dysphagia, chest pain, postprandial discomfort, and dyspnea or shortness of breath.¹ Although rare, this hernia can progress, leading to severe complications such as gastric volvulus, angina, and even cardiac perforation.², ³ When symptoms appear, as in this particular case, surgical treatment is usually recommended to avoid severe complications and increasing symptoms.¹

However, our patient presented only dyspnea, which could be explained by the lung arrest provoked by the hernia. The inverted position of the stomach points to the possibility of a gastric volvulus, and the patient was informed about this risk. Surgical treatment was proposed to the patient, who refused it. She is doing well, with no changes in her chronic symptoms.

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References 

1. Maziak DE, Todd TRJ, Griffin Pearson F. Massive hiatus hernia: evaluation and surgical management. J Throac Cardiovasc Surg. 1998;115:53–60
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2. Blum MG, Sundaresan RS. Giant hiatal hernia with gastric volvulus complicating pneumectomy. Ann Thorac Surg. 2006;81:1491–1492
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3. Akdemir I, Davutoglu V, Aktaran S. Giant hiatal hernia presenting with stable angina pectoris and syncope—a case report. Angiology. 2001;52:863–865
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