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Type IV para-oesophageal hiatal hernia: it’s a gut feeling
  1. Farzan Irani,
  2. Vijay Mahajan
  1. St Vincent Mercy Medical Center, Internal Medicine, Toledo, Ohio, 43608, USA
  1. farzan_i{at}hotmail.com

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An 89-year-old woman presented with epigastric pain and nausea of 1 day duration. Examination revealed epigastric tenderness with positive bowel sounds and absent breath sounds at both lung bases. A frontal view of the chest (fig 1A) revealed a very large intrathoracic gastric bubble occupying both lower lung fields (marked by arrows). An air fluid level on the right lateral decubitus film (fig 1B) confirmed an intrathoracic stomach. An emergent explorative laparotomy revealed a large type IV para-oesophageal hernia with the omentum, transverse colon, and entire stomach herniating through a large diaphragmatic defect in the chest. There was no evidence of strangulation. These were reduced and a Stamm gastrostomy with gastropexy was performed. She was discharged after an uneventful recovery.

Figure 1 (A) Frontal chest x ray revealing a large intrathoracic gastric bubble (arrows).

(B) Air fluid level confirming intrathoracic gastric contents on the right lateral decubitus chest x ray (arrow).

Type IV para-oesophageal hernias are defined by intrathoracic herniations of abdominal viscera such as colon, omentum, small bowel and liver in addition to the stomach.1 This is the least common type of para-oesophageal hiatal hernias which account for around 5% of all hiatal hernias. Gastric volvulus, gangrene, perforation and recurrent pneumonias can complicate their course. Incarceration and strangulation of the stomach are potentially life threatening and could present with minimal symptoms. Retro cardiac gas filled structures may be noted on chest radiographs.

Para-oesophageal hernias tend to occur in the elderly with significant co-morbidities. If left untreated, severe complications develop in 30–45% with a 50% mortality rate. Emergent surgery is associated with poor outcomes. Hence routine surgical repair is recommended, regardless of type or associated symptoms. The newer laparoscopic hernia repair technique offers a minimally invasive approach in this patient age group, with favourable outcomes and low recurrence rates.2 Timely recognition of these hernias is essential, to prevent unnecessary mortality and morbidity.

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Footnotes

  • Competing interests: none.

  • Patient consent: Patient/guardian consent was obtained for publication

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