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Interesting Case Rounds
Yael Moussadji, R5July 24, 2008
+Case
93 y/o f
HPI Chest and upper abdo pain for 12 hours Vomited x4, coffee ground emesis No melena, diarrhea, urinary symptoms, fever, or cough Squeezing pain, non-radiating, non-migrating, non-exertional,
onset unclear
PMHx HTN, hypothyroid, prior pelvic fracture, hysterectomy, TKR No CAD/DM/CVD/PE risk factors (except in nursing home) No prior PUD/liver disease/EtOH Meds: HCTZ, losartan, pantoloc, Ca, Vit D (no NSAIDS)
+Case
P/E Alert Afebrile, HR 112, BP 155/85, SpO2 normal on R/A Normal CV, resp, neuro, and skin exam Moderate tenderness of the upper abdomen Rectal: no blood or melena EDTU: indeterminate scan
Labs Hb 81 (113 on July 7), MCV 90 WBC 11, Cr 175 (100 on July 7) Liver enzymes and lipase normal TNT –ve, urine -ve
+Differential Diagnosis of Chest Pain
Cardiac
Vascular
Pulmonary
GI
MSK
+Investigations
Labs
ECG
CXR
+CT chest
+Barium Swallow
+Hiatal Hernias
Occurs when a portion of the stomach prolapses through the diaphragmatic esophageal hiatus
Most are asymptomatic and are discovered incidentally
Rarely, can result in life threatening gastric volvulus or strangulation (type II)
More common in Western countries (fiber-deplete diets), and in women (pregnancy)
Frequency increases with age; occurs in 10% of patients <40 and 70% of patients >70
+Types
Sliding hiatal hernia (Type I) Most common Occurs when GE junction, along with a portion of the
stomach, migrates into the mediastinum through the esophageal hiatus
Paraesopahageal hernia (Type II) Also called rolling-type hiatal hernia Widened hiatus permits fundus of the stomach to protrude
into the chest anterior and lateral to the esophagus GE junction remains below diaphragm, causing the stomach
to rotate in a counter clockwise direction Distinguished from hiatal hernias by whether or not the
esophagogastric junction (cardia) is above or below the diaphragm
+Types
Type III - Mixed Mixed sliding and paraesophageal component Largest group of patients with paraesophageal hernias
Type IV - Complex Involves spleen, liver, colon
+Types of Hiatal Hernias
+Sliding Hiatal Hernias (Type I)
95% of all hiatal hernias; majority of patients are asymptomatic
Younger patients, obesity, pregnancy; median age 48
Main symptoms are those associated with GERD; may predispose to or worsen symptoms (increases contact time of gastric juices with esophagus); found in 90% of those with severe GERD
Interferes with the reflux barrier mechanism; as the LES moves into the chest, it is no longer exposed to the intra-abdominal pressures and becomes less effective; there is a loss of the angle between the cardia and the distal esophagus
Main complications are those associated with GERD
+Hiatal Hernia
+Paraesophageal Hernia (Type II)
5% of all hiatal hernias
Tend to enlarge with time; older patients (most are > 70); M:F ratio 1:4
Fundus eventually comes to lie above the GE junction and pulls pylorus toward diaphragmatic hiatus; anatomic relation of stomach to esophagus is unchanged, so does not cause acid reflux
Risk of incarceration, perforation, or strangulation is 5-30%; with emergency surgery, carries a mortality of 15-20%
Other chronic to sub-acute symptoms may persist: postprandial discomfort; N/V; hiccough; belching; dysphagia; chest gurgling; vague, intermittent chest discomfort or pain
+Paraesophageal hernia (Type II)
+Paraesophageal Hernias: Clinical Features
Most are symptomatic Most commonly present with symptoms related to the space-
occupying nature of the hernia within the chest Post-prandial fullness, dysphagia, CP syndromes, dyspnea
Obstruction results in dysphagia, gastric ulceration, aspiration, and vascular compromise
One third of patients are anemic due to gastric ulceration and chronic mucosal venous engorgement
Respiratory complications consist of dyspnea from mechanical compression and recurrent pneumonia from aspiration
AF level may be seen behind cardiac silhouette
+Paraesophageal hernias: Complications
Space-occupying Intra-thoracic stomach Pulmonary complications, dyspnea, aspiration
Bleeding Venous engorgement, mucosal ulceration, ischemia, occult
iron-deficiency anemia
Mechanical Obstruction, incarceration, volvulus Ischemia and perforation
+Imaging
Barium Upper GI Series
Endoscopy
CT chest
+Hiatal Hernia
+Hiatal Hernia
+Management: Incidental Finding in ED
Hiatal Hernia With GERD
Responds well to PPIs (no benefit to surgery); surgery for those with intractable symptoms
Without GERD Do nothing Instruct patients to seek care if symptoms of GERD
develop
Paraesophageal Hernia In all patients, requires laparoscopic repair to prevent
life-threatening complications Can discuss outpatient follow-up with surgery (upper GI
or thoracics)
+Surgical Care
Anti-reflux procedures Nissen fundoplication
360 degree fundic wrap around GE junction and repair of diaphragmatic hiatus
Belsey (Mark IV) fundoplication 270 wrap (prevents bloating and dysphagia)
Hill repair Cardia anchored to posterior abdomen
Paraesophageal repair Goal to remove the hernia sac and close abnormally
widened esophageal hiatus +/- stomach anchoring
+Gastric Volvulus
In rare cases, the entire stomach may herniate into the chest and undergo volvulus and subsequent incarceration and strangulation
Clinical presentation: vomiting, chest pain radiating to the back or shoulders, dyspnea; may have an unremarkable abdominal exam
Combination of severe epigastric pain and distention, vomiting, and inability to pass an NG = Borchart’s triad
Classified on the basis of the axis of rotation: most common form is organoaxial which occurs when the stomach twists on its long axis
+Gastric Volvulus: Management
Goal of treatment is reduction
Attempt passage of an NG to decompress stomach, which may reduce volvulus
Endoscopic reduction or surgery
+Take Home Points
Most hiatal hernias will be an incidental finding in the ED
Sliding hiatal hernias require no follow-up; treat with PPIs if GERD present
Paraesophageal hernias (5%) require surgical follow-up as up to 30% will suffer catastrophic complications
If a patients presents with a suspected complication of paraesophageal hernia (gastric volvulus, strangulation, perforation), decompress with NG
CT with oral contrast or barium swallow is the diagnostic procedure of choice; gastrografin for suspected perforation