Symptomatic Giant Hiatal Hernia with Intrathoracic Stomach
Savio George Barreto, Shailesh V. Shrikhande in Dilemmas in Abdominal Surgery, 2020
A hiatal hernia is an abnormal protrusion of some, or even all, of the stomach into the thoracic cavity via the esophageal hiatus. Hiatal herniae are subcategorized into four types. The overwhelming majority of hiatal herniae are type I (sliding), which involves displacement of the gastroesophageal junction above the esophageal hiatus but the fundus remaining in the abdomen. Type II (paraesophageal) involves herniation of the gastric fundus through the esophageal hiatus while the gastroesophageal junction remains at the level of the hiatus. Type III (mixed) is a combination of type I and type II herniae where both the gastroesophageal junction and the fundus have herniated into the chest. Type IV herniae can be any of the above but occur when other structures, such as colon or small bowel, are found in the hernia sac [1]. While generally presenting de novo, a proportion may be recurrent following previous attempted hiatal hernia repair or anti-reflux surgery.
Electrocoagulation Of Vascular Abnormalities Of The Large Bowel
John P. Papp in Endoscopie Control of Gastrointestinal Hemorrhage, 2019
Case 2: This 62-year-old woman presented with intermittent passage of black and burgundy-red stools for 9 months. She also had paresthesias of the lower extremities and intermittent claudication. Translumbar aortography showed arteriosclerosis obliterans with severe, nearly total occlusion of the distal abdominal aorta approximately 2 cm above the bifurcation. She was also found to be anemic, with a hemoglobin of 8.4 g/d/. Stools were 4+ positive for occult blood. X-ray studies of the gastrointestinal tract and proctosigmoidoscopy failed to reveal the source of bleeding. It was decided that further investigation of her gastrointestinal bleeding was necessary before a surgical bypass could be performed for her vascular disease. Upper intestinal endoscopy showed a hiatal hernia only. At colonoscopy four, bright-red, mucosal vascular abnormalities were seen in the base of the cecum. The largest was 1 cm in diameter. All were electrocoagulated with the dome-tip electrode. It was noted that just touching the vascular abnormalities with the electrode caused fairly profuse bleeding. The patient was discharged from the hospital on the following day, and 3 months later had her aorto-ilio Dacron bypass. Shortly after the patient’s surgery, she had one more episode of bright-red rectal bleeding, but none since (6 years).
Post-esophagectomy Colon Diaphragmatic Herniation
Wickii T. Vigneswaran in Thoracic Surgery, 2019
Hiatal hernia after esophagectomy is a recognized complication. Routine closure of the crura as a part of the esophagectomy is practiced by most if not all experienced esophageal surgeons [1–3] and was performed in this patient. Regardless of setting (e.g., post-esophagectomy or in case of isolated hiatal hernia with no prior operation), surgery is the recommended treatment for large, symptomatic hiatal hernias [4]. Torsion of the superiorly displaced abdominal organs is a feared sequalae. Bleeding after surgery is an unfortunate complication, made even more frustrating when no source is identified when the patient is brought to the operation for exploration. The surgical team must be aware of signs of bleeding and not delay a return trip to the operating room. Here, a drop in the blood count followed by an opaque radiograph was sufficient evidence; further studies would have only delayed the care of the patient unnecessarily.
Percutaneous endoscopic gastrostomy: a dislodgement complication due to a moving hiatal hernia
Published in Scandinavian Journal of Gastroenterology, 2021
Miia L. Lehtinen, Ilkka Ilonen, Juha Kauppi, Jari Räsänen
The EGD performed in a secondary care center revealed a large Zenker’s diverticulum (ZD) in the proximal esophagus. No passage was gained distal to ZD. A large concomitant hiatal hernia was also suspected in the chest x-ray. As the patient had malnourishment due to dysphagia, resulting in severe progressive weight loss, need for an enteral feeding route was urgent and the patient was referred to a tertiary center. Surgical treatment for ZD was discussed but to improve the nutritional status before definitive surgery, the patient was consented for PEG insertion under general anesthesia. Passage distal to ZD in the EGD was time-consuming. When finally entering the stomach, a type-III uncomplicated paraesophageal hernia was noted. After an endoscopic repositioning maneuver, passage to duodenum was gained. Cutaneous transillumination was visible in the abdominal wall and a 20-Fr MIC-PEG tube (Halyard, GA, USA) was inserted using the pull-technique. A repeat EGD was abandoned due to the complicated passage distal to the ZD. A computed tomography (CT) was performed after the insertion, confirming the suspected large hiatal hernia with 50% of the stomach detected above the diaphragm plane. The MIC-PEG location was satisfactory in the gastric body below the diaphragm (Figure 1(A and B)).
Endoscopic measurement of hiatal hernias: is it reliable and does it have a clinical impact? Results from a large prospective database
Published in Postgraduate Medicine, 2023
Charles Christian Adarkwah, Oliver Hirsch, Merlissa Menzel, Joachim Labenz
It is thus conceivable that gastroesophageal reflux disease (GERD) is often associated with the presence of a hiatal hernia, thereby the hernia can be the precipitating as well as the maintaining factor [4]. However, small hernias frequently remain asymptomatic, while larger hernias often cause a variety of symptoms [5]. According to the Montreal definition, typical reflux symptoms are troublesome heartburn and/or regurgitation [6]. Both GERD and hiatal hernias occur more frequently with increasing age and weight. The risk factors for a hiatal hernia are very similar to those of reflux disease, i.e. especially high intra-abdominal pressure, caused e.g. by obesity or pregnancy, and increasing age play a decisive role here. After the age of 50, about 55–60% of people have a hiatal hernia, but only 9% suffer from clinical symptoms [5,7].
Black esophagus: a case series and literature review of acute esophageal necrosis
Published in Scandinavian Journal of Gastroenterology, 2018
C. R. Lamers, W. G. N. Mares, D. J. Bac
A 38-year-old male with history of diabetes mellitus type 2, recurrent pancreatitis, and alcohol and drug abuse presented to our emergency department with hematemesis and abdominal pain. On physical examination, the patient was hypotensive at 90/50 mmHg, tachycardic at 112 beats per minute, and there was epigastric tenderness. Laboratory analysis revealed hemoglobin of 6.5 mmol/L, white blood cell count of 7.6/nL, serum creatinine of 179 μmol/L, urea of 34.1 mmol/L, glucose of 30.8 mmol/L, and albumin of 33 g/L. He was transferred to the ICU were an EGD was performed. This showed a circumferential necrotizing esophagitis of the entire esophagus with edema, ulcers, purulent exudates, and a serious arterial bleeding in the distal esophagus (Figure 1.3). After local injection of adrenalin the bleeding stopped. Additionally, a hiatal hernia was noted. The patient was transfused two units of packed red blood cells. He was treated with nil-per-os restriction, intravenous fluids, high-dose pantoprazole, octreotide, total parenteral nutrition, insulin therapy, and intravenous amoxicillin-clavulanate. Repeat EGD 5 days later still showed circumferential esophagitis although it had evidently improved. The patient was discharged in a stable condition.
Related Knowledge Centers
- Chest Pain
- Dysphagia
- Heartburn
- Hernia
- Abdomen
- Stomach
- Mediastinum
- Thoracic Diaphragm
- Gastroesophageal Reflux Disease
- Laryngopharyngeal Reflux