2000 Associates' Presentations
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Hiatal Hernia: From the Abdomen to the Thorax
Ellena L. Henderson, MD, Medical College of Wisconsin, Milwaukee, WI
My patient is an 84 yo African American woman who presented with complaints of progressive dyspnea at rest, fatigue and early satiety for two months. An echocardiogram revealed an extracardiac mass obliterating portions of the left and right atrium. LV function was normal. Radiographic evaluation, most importantly UGI, revealed herniation of the stomach to the proximal duodenal bulb into the thorax. Surgical intervention is the only treatment in this situation. The patient was warned of the complications of foregoing such treatment including obstruction, strangulation, incarceration, perforation, and death. She refused surgery and was discharged home.
A hiatal hernia is defined as a prolapse of a portion of the stomach through the diaphragmatic esophageal hiatus. It may be congenital or acquired. Acquired forms are further classified into traumatic and atraumatic. The types of atraumatic hernias include hiatal (sliding), paraesophageal (rolling), mixed, and the intrathoracic stomach.
Stomach migration into the thorax involves rotation about its long axis, which keeps the lesser curvature in the abdomen. The greater curvature is therefore mobile and able to rotate about this axis anteriorly and upward. As the defect enlarges, the fundus, body, and antrum herniate into the chest (cardia and pylorus remain in the abdomen). This results in the stomach residing in a "upside down" position in the thorax.
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Sharon Haase, MD, FACP
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