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Clinical Images  |   March 2018
Strangulated Paraesophageal Hiatal Hernia
Author Notes
  • From the Advocate Lutheran General Hospital in Park Ridge, Illinois. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Ryan Hoff, DO, Advocate Lutheran General Hospital, 1775 Dempster St, Park Ridge, IL 60068-1143. Email: ryan.hoff@advocatehealth.com
     
Article Information
Gastroenterology / Imaging / Ophthalmology and Otolaryngology / Pulmonary Disorders / Clinical Images
Clinical Images   |   March 2018
Strangulated Paraesophageal Hiatal Hernia
The Journal of the American Osteopathic Association, March 2018, Vol. 118, 207. doi:10.7556/jaoa.2018.042
The Journal of the American Osteopathic Association, March 2018, Vol. 118, 207. doi:10.7556/jaoa.2018.042
A 76-year-old man was admitted to the hospital with nonexertional epigastric pain radiating to the lower chest. His medical history included gastroesophageal reflux disease. Plain-film (single view) radiographic chest images demonstrated a large hiatal hernia (image A). A nothing-by-mouth diet was prescribed, but the patient continued to have significant epigastric discomfort. Nasogastric intubation resulted in drainage of 3 L of gastric secretions. Computed tomographic images without contrast demonstrated a large strangulated paraesophageal hernia (image B, arrow). The patient underwent robotic-assisted laparoscopic repair of the hernia with surgical mesh. His postoperative course was complicated by sepsis, which resolved after a short course of cefepime. 
Paraesophageal hernias are less common and more severe than sliding hernias. Symptoms may include chest pain, abdominal pain, or respiratory distress. The rate of progression to symptoms is about 14% per year.1 Complications include obstruction, bleeding, strangulation, perforation, respiratory compromise, and gastric volvulus.1 All symptomatic and any complicated paraesophageal hiatal hernias should be surgically repaired, usually laparoscopically.1 Surgical repair improves quality of life and mortality rates,2 and recurrences are rare.3 
References
Kohn GP, Price RR, DeMeester SR, et al Guidelines for the management of hiatal hernia. Surg Endosc. 2013;27(12):4409-4428. doi: 10.1007/s00464-013-3173-3 [CrossRef] [PubMed]
Le Page PA, Furtado R, Hayward M, et al Durability of giant hiatus hernia repair in 455 patients over 20 years. Ann R Coll Surg Engl. 2015;97(3):188-193. doi: 10.1308/003588414X14055925060839 [CrossRef] [PubMed]
White BC, Jeansonne LO, Morgenthal CB, et al Do recurrences after paraesophageal hernia repair matter? ten-year follow-up after laparoscopic repair. Surg Endosc. 2008;22(4):1107-1111. doi: 10.1007/s00464-007-9649-2 [CrossRef] [PubMed]