+

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