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Electronic Clinical Challenges and Images in GI
Electronic Clinical Challenges and Images in GI
Image 4
Question: An 84-year-old woman presented to the emergency department with acute stridor. She denied any known provoking factor for her symptom. Previously, her only medical history was dysphagia 4 years ago. Gastroscopy diagnosed a hiatal hernia at that time. However, her symptom resolved with dietary changes. Clinical examination was unremarkable. Chest x-ray showed widened upper mediastinum with air–fluid level (Figure A, Figure B). What is the most likely diagnosis?
BARANI S. MAYILVAGANAN, MBBS CHUAN G. CHOO, MRCP University Hospital of North Staffordshire North Staffordshire, UK © 2007 by the AGA Institute
0016-5085/07/$32.00 doi:10.1053/j.gastro.2007.10.036
GASTROENTEROLOGY 2007;133:e3– e4
e4
GASTROENTEROLOGY Vol. 133, No. 6
Answer to the Clinical Challenges and Images in GI Question Image 4: Acute stridor caused by hiatal hernia Urgent computed tomography of the thorax showed that the hiatal hernia extended into thoracic cavity. Diagnosis of hiatal hernia causing tracheal compression was made. She was transferred to the operating room for emergency hiatal hernia repair within 4 hours of arrival at the emergency department. Laparoscopic fundoplication was performed. After the operation, she was transferred to the intensive care unit for supportive care. Rigid bronchoscopy performed 48 hours later confirmed no endobronchial or tracheal obstruction. She was extubated without complication and discharged a week later. Several known causes of widened mediastinum on chest radiography include bronchogenic carcinoma, bronchogenic cyst, aortic dissection, lymphoproliferative disease, thymoma and achalasia. We have not found any similar presentation of hiatal hernia from our English literature search. Hiatal hernia is commonly an incidental finding on chest radiograph. The frequency of hiatal hernia ranges from 40% to 70%. Predisposing factors are aging and obesity. In our case, this lady is elderly but she has a normal body mass index. Often, hiatal hernia is asymptomatic. Other presentations include chest pain, postprandial fullness, retching, and dysphagia. Respiratory complications do occur as a result of mechanical compression of the lung. From our English literature search, we have not found any case report to describe hiatal hernia causing acute stridor. Achalasia1–3 has been known as a rare cause of airway obstruction, which may involve the presence of a megaesophagus.1 References 1. Wagh MS, Matloff DS, Carr-Locke DL. Life-threatening acute airway obstruction in achalasia. MedGenMed 2004;6:12. 2. Lund J, Andreassen UK, Sommer WK. Acute upper airway obstruction caused by esophageal achalasia—a rare complication. Ugeskr Laeger 1994;156:3190 –3191. 3. Moloney JR, Carr-Locke DL, Cookson JB. Stridor due to an achalasia-like condition of the oesophagus. J Laryngol Otolaryngol 1987;101:1297–1300. For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).
Image 4
Question: An 84-year-old woman presented to the emergency department with acute stridor. She denied any known provoking factor for her symptom. Previously, her only medical history was dysphagia 4 years ago. Gastroscopy diagnosed a hiatal hernia at that time. However, her symptom resolved with dietary changes. Clinical examination was unremarkable. Chest x-ray showed widened upper mediastinum with air–fluid level (Figure A, Figure B). What is the most likely diagnosis?
BARANI S. MAYILVAGANAN, MBBS CHUAN G. CHOO, MRCP University Hospital of North Staffordshire North Staffordshire, UK © 2007 by the AGA Institute
0016-5085/07/$32.00 doi:10.1053/j.gastro.2007.10.036
GASTROENTEROLOGY 2007;133:e3– e4
e4
GASTROENTEROLOGY Vol. 133, No. 6
Answer to the Clinical Challenges and Images in GI Question Image 4: Acute stridor caused by hiatal hernia Urgent computed tomography of the thorax showed that the hiatal hernia extended into thoracic cavity. Diagnosis of hiatal hernia causing tracheal compression was made. She was transferred to the operating room for emergency hiatal hernia repair within 4 hours of arrival at the emergency department. Laparoscopic fundoplication was performed. After the operation, she was transferred to the intensive care unit for supportive care. Rigid bronchoscopy performed 48 hours later confirmed no endobronchial or tracheal obstruction. She was extubated without complication and discharged a week later. Several known causes of widened mediastinum on chest radiography include bronchogenic carcinoma, bronchogenic cyst, aortic dissection, lymphoproliferative disease, thymoma and achalasia. We have not found any similar presentation of hiatal hernia from our English literature search. Hiatal hernia is commonly an incidental finding on chest radiograph. The frequency of hiatal hernia ranges from 40% to 70%. Predisposing factors are aging and obesity. In our case, this lady is elderly but she has a normal body mass index. Often, hiatal hernia is asymptomatic. Other presentations include chest pain, postprandial fullness, retching, and dysphagia. Respiratory complications do occur as a result of mechanical compression of the lung. From our English literature search, we have not found any case report to describe hiatal hernia causing acute stridor. Achalasia1–3 has been known as a rare cause of airway obstruction, which may involve the presence of a megaesophagus.1 References 1. Wagh MS, Matloff DS, Carr-Locke DL. Life-threatening acute airway obstruction in achalasia. MedGenMed 2004;6:12. 2. Lund J, Andreassen UK, Sommer WK. Acute upper airway obstruction caused by esophageal achalasia—a rare complication. Ugeskr Laeger 1994;156:3190 –3191. 3. Moloney JR, Carr-Locke DL, Cookson JB. Stridor due to an achalasia-like condition of the oesophagus. J Laryngol Otolaryngol 1987;101:1297–1300. For submission instructions, please see the Gastroenterology website (http://www.gastrojournal.org).