Larkin Community Hospital Miami, FL, United States
Mihir Brahmbhatt, MD, Humberto Rios, MD, Micaella Kantor, MD, Luis Nasiff, MD, FACG Larkin Community Hospital, Miami, FL
Introduction: There are four distinct types of hiatal hernia (HH) based on extent of the herniated viscera. Type I HH are the most common, with the rarer types II-IV which allow the stomach and other viscera to herniate alongside the esophagus. Type IV HH are considered the rarest with involvement of the stomach along with upper abdominal organs. The following case presentation would be an unusual presentation of an asymptomatic giant HH with transverse colon involvement.
Case Description/Methods: A 95-year-old female with past medical history of hypertension, diabetes mellitus type 2, and trigeminal neuralgia presented to the emergency department (ED) due to dysuria. Patient ED evaluation received an abdominal x-ray which incidentally demonstrated a large HH involving the stomach and dilated loops of bowel. Patient also received a CT abdomen and pelvis which confirmed a type IV HH involving portions of the transverse colon. A small bowel follow through noted no obstruction.
Patient during the course of hospitalization denied any abdominal pain, vomiting, nausea, dyspnea, or chest pain. Patient was noted to have a mild leukocytosis, thrombocytosis, normal lactic acid but otherwise unremarkable laboratory values. Patient on exam was noted to have a soft, non-distended, non-tender abdomen, and remained afebrile, and normotensive throughout course of hospitalization.
Considering her non-acute abdomen, stable vitals, advanced age and without evidence of complications; surgical management deemed not necessary and was discharged on an aggressive bowel regimen.
Discussion: Asymptomatic giant type IV HH is an unusual finding, with two long duration studies noting only one asymptomatic case of giant type IV HH.1,2 Management of HH is either observation or surgical repair. In this case, the patient’s HH had no complications or symptoms. This case report illustrates the importance of maintaining vigilance for the incidental findings of HH.
1. Maziak DE, Todd TRJ, Pearson FG, et al. Massive hiatus hernia: Evaluation and surgical management. J Thorac Cardiovasc Surg. 1998;115(1):53-62. doi:10.1016/S0022-5223(98)70442-8
2. Patel HJ, Tan BB, Yee J, et al. A 25-year experience with open primary transthoracic repair of paraesophageal hiatial hernia. J Thorac Cardiovasc Surg. 2004;127(3):843-849. doi:10.1016/j.jtcvs.2003.10.054
Figure: Imaging results. a: Abdominal x-ray indicating type IV hiatal hernia. (2020); b: CT abdomen and pelvis scout film from prior admission (2014); c: Small bowel follow through (2020); d: CT abdomen and pelvis (2020)
Disclosures: Mihir Brahmbhatt indicated no relevant financial relationships. Humberto Rios indicated no relevant financial relationships. Micaella Kantor indicated no relevant financial relationships. Luis Nasiff indicated no relevant financial relationships.
Mihir Brahmbhatt, MD, Humberto Rios, MD, Micaella Kantor, MD, Luis Nasiff, MD, FACG. P2443 - Asymptomatic Presentation of Giant Paraoesophageal Hernia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.