Teaching Case

Hiatus hernias are common behind the heart and easily seen on chest X-rays. The sizes of them can be variable as well as the contents. This case demonstrates an unusually large hiatus hernia with a lot of viscera.

An 86-year-old lady presented with exertional dyspnoea and wheeze. She never smoked or had any history of chest injuries. Previous medical history included mild heart failure and chronic immune thrombocytopenia for which she took prednisolone and azothioprine. Examination showed reduced basal air entry with expiratory wheeze and mild ankle oedema. Recent CXR showed possible left lower lobe collapse or diaphragmatic eventration on the left making interpretation difficult. A staging CT chest examination was requested.
The resulting CT chest show a massive intra-thoracic hiatus hernia containing the entire stomach, the first part of the duodenum, small bowel loops, the pancreas (head, body and tail) and large bowel (proximal transverse colon to splenic flexure). The liver and spleen were of normal size, in their normal positions and enhanced normally. The splenic vein was kinked inside the hernia. The left lung was a little compressed at the base, but was otherwise of normal appearance with a normal right lung. The patient was subsequently discharged from respiratory follow-up.

Intra-thoracic extension of hiatus hernia is demonstrated well on multi-slice CT scanning with coronal reformatted image (1).
Diaphragmatic hernias are the most common gastrointestinal abnormality, especially in elderly patients (2). Presenting symptoms can vary from nothing (often found incidentally), to heartburn, vomiting, dysphagia, chest pain, anaemia and weight loss. In one series of 94 patients, 56% had post prandial pain, 48% had dysphagia, 38% had chronic iron deficiency anaemia and aspiration in 29% (3). In another series over 23 years, 15 out of 53 (28%) patients with massive thoracic incarcerated hernias, presented with severe dyspnoea. 24 of 53 (45%) were associated with organo-axial volvulus, 43/53 (81%) had post-prandial distress and 24/53 (45%) had upper GI bleeding (4).
The oesophageal hiatus at the diaphragm can have a variable size. It will normally narrow with rising intra-abdominal pressure. Most hernias are small with perhaps 2 cm of the gastric fundus passing through the hiatus and between the diaphragmatic crura. Large hernias may be entirely intra-thoracic with predisposition to torsion or volvulus. Para-oesophageal hernias tend to pass to the left of the distal oesophagus and enlarge into the posterior mediastinum. About 5% of these will incarcerate leading strangulation and perforation. Traumatic hernias can occur after a diaphragmatic tear after penetrating injuries or a forceful rise of intra-abdominal pressure (5). Gallimidi et al, describe a rare case of herniation of the left lobe of the liver through the gastroesophageal hiatus (6).
Migration of the pancreas into the chest is rare. It was described in the literature, but not as significantly in the case we describe. In 1987, Coral et al, described a posterior diaphragmatic hernia containing pancreas (initially thought to be a pulmonary sequestration) on CT (11). Chevallier et al, describe a case of acute pancreatitis caused by a pancreatic volvulus through a large hiatus hernia. The pancreatic tail and body were in the retro-crural space, the head was in its anatomical position with a normal left to right orientation. The stomach may be associated with other abdominal viscera including colon, most often the splenic flexure and small bowel loops (7).
Splenic capsular laceration with severe haemorrhage after forceful retching has been described in a patient with an incarcerated hiatus hernia (10).
Gurgun et al, described a giant paraoesphageal hernia detected on barium swallow causing dyspnoea in a patient with a cardiac history. Symptoms resolved after elective laparoscopic repair of the hernia (8).
Treatment of asymptomatic hernias has included watchful waiting and elective repair. The annual probability of developing acute symptoms requiring emergency surgery was 1.1%. If elective repair is recommended, it is more beneficial than watchful waiting in only 17% patients (9). Other groups recommend elective repair of ‘giant’ hernias to prevent potential complications of gastric volvulus, obstruction and ischaemic perforation (10).