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Type 4 Hiatal Hernia
ONLINE IMAGES IN THE MEDICAL SCIENCES
Type 4 Hiatal Hernia Abhishek Maiti, MBBS,* Debjit Saha, MBBS and Arnab Basu, MBBS, MPH *
Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas (E-mail: [email protected]). The authors have no financial or other conflicts of interest to disclose.
FIGURE.
CASE PRESENTATION
A
92-year-old man with hypertension and atrial fibrillation presented with abdominal pain and fever for 1 day. On physical examination, bowel sounds were heard over the right infra-axillary region; the abdomen was scaphoid, soft, with suprapubic tenderness. An initial upright chest radiograph showed marked distortion of the cardiomediastinum due to large gascontaining structures in the lower portion of the thorax (Figure A). A computed tomogram of chest and abdomen (Figure B) showed a type 4 hiatal hernia with intrathoracic herniation of the stomach (white arrow) and part of the small and large bowel (star). Urinalysis confirmed a urinary tract infection, and the patient improved with ceftriaxone. Given the asymptomatic nature of the hiatal hernia and old age of the patient, decision was taken to forgo any surgical intervention. A hiatal hernia is defined as herniation of stomach through the esophageal hiatus into the thorax. The most advanced form classified as type 4 hiatal hernia involves herniation of stomach and other organs like small or large bowel or spleen into the chest through a
large defect of the phrenoesophageal membrane.1 Advanced hiatal hernia can present with postprandial pain, dysphagia, reflux symptoms, aspiration or iron deficiency anemia.1 Patients can develop peptic or ulcerative esophagitis. Repair of the hernia by fundoplication, gastropexy, sometimes with prosthetic mesh can be undertaken both by laparoscopic or open approach.2 The laparoscopic approach, although being more popular, has been reported to have higher recurrence rates of herniation compared to the open approach.3 At 1-year follow-up the patient continued to be asymptomatic.
REFERENCES 1. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol 2008;22(4): 601–16. 2. Maziak DE, Todd TRJ, Pearson FG. Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 1998;115(1):53–62. 3. Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate1. J Am Coll Surg 2000;190(5):553–60.
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved. VOLUME 351 NUMBER 3 March 2016 www.amjmedsci.com www.ssciweb.org
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Type 4 Hiatal Hernia Abhishek Maiti, MBBS,* Debjit Saha, MBBS and Arnab Basu, MBBS, MPH *
Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas (E-mail: [email protected]). The authors have no financial or other conflicts of interest to disclose.
FIGURE.
CASE PRESENTATION
A
92-year-old man with hypertension and atrial fibrillation presented with abdominal pain and fever for 1 day. On physical examination, bowel sounds were heard over the right infra-axillary region; the abdomen was scaphoid, soft, with suprapubic tenderness. An initial upright chest radiograph showed marked distortion of the cardiomediastinum due to large gascontaining structures in the lower portion of the thorax (Figure A). A computed tomogram of chest and abdomen (Figure B) showed a type 4 hiatal hernia with intrathoracic herniation of the stomach (white arrow) and part of the small and large bowel (star). Urinalysis confirmed a urinary tract infection, and the patient improved with ceftriaxone. Given the asymptomatic nature of the hiatal hernia and old age of the patient, decision was taken to forgo any surgical intervention. A hiatal hernia is defined as herniation of stomach through the esophageal hiatus into the thorax. The most advanced form classified as type 4 hiatal hernia involves herniation of stomach and other organs like small or large bowel or spleen into the chest through a
large defect of the phrenoesophageal membrane.1 Advanced hiatal hernia can present with postprandial pain, dysphagia, reflux symptoms, aspiration or iron deficiency anemia.1 Patients can develop peptic or ulcerative esophagitis. Repair of the hernia by fundoplication, gastropexy, sometimes with prosthetic mesh can be undertaken both by laparoscopic or open approach.2 The laparoscopic approach, although being more popular, has been reported to have higher recurrence rates of herniation compared to the open approach.3 At 1-year follow-up the patient continued to be asymptomatic.
REFERENCES 1. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol 2008;22(4): 601–16. 2. Maziak DE, Todd TRJ, Pearson FG. Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 1998;115(1):53–62. 3. Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate1. J Am Coll Surg 2000;190(5):553–60.
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved. VOLUME 351 NUMBER 3 March 2016 www.amjmedsci.com www.ssciweb.org
e5