A surgical emergency due to an incarcerated paraesophageal hernia

Paraesophageal hernias (PEHs) are hernias in which the gastroesophageal junction stays where it belongs (attached at the level of the diaphragm), but part of the stomach passes or bulges into the chest beside the esophagus. It represents a small proportion of all hiatal hernias. It can lead to severe complications like incarceration, volvulus, or strangulation, which are true emergencies in the emergent department (ED). Paraesophageal hernia rarely features on a list of differential diagnoses of acute chest or epigastric pain. It could be treated as myocardial insult, and the outcome could be life-threatening. Thus, it is easily missed when ED physicians did not maintain a high index of suspicion. Multislice thoracoabdominal computed tomography scan is a very useful and reliable tool for diagnosis and detecting complications. Surgical repair of PEH provide excellent outcomes and have low complication rate compared with laparoscopic approach in the literature. Correct diagnosis and treatment can prevent life-threatening complications. We reported a case of PEH with incarceration of stomach and colon with initial presentations of nonspecific epigastralgia and anterior chest pain. It highlights the challenge that noncardiac chest pain presents to the ED physician. Paraesophageal hernias (PEHs) are hernias in which the gastroesophageal junction stays where it belongs (attached at the level of the diaphragm), but part of the stomach passes or bulges into the chest beside the esophagus. It represents a small proportion of all hiatal hernias [1]. It can lead to severe complications like incarceration, volvulus, or strangulation, which are true emergencies in the emergent department (ED). We reported a case of PEH with incarceration of stomach and colon with initial presentations of nonspecific epigastralgia and anterior chest pain in the ED. An 84-year-old man presented with epigastralgia for 2 days at our ED with a history of benign prostate hypertrophy, osteoporosis, and associated L2 vertebral compression fracture. He had habits of drinking alcohol and smoking. In addition, he had had dysphagia for months. He denied hyperlipidemia, peptic ulcer disease, recent trauma, and a history of surgery except a transurethral resection of the prostate. On arrival in our ED, he presented with intolerant epigastralgia and anterior chest pain that was radiating to the back. Initial electrocardiography was unremarkable except for left ventricular hypertrophy. No subdiaphragmatic free air was documented in the upright chest radiography. Unfortunately, a visceral gas in the mediastinum was missed in the image reading by the duty ED physician (Fig. 1). Laboratory results were as follows: troponin I <0.01 ng/dL, amylase 61 U/L, lipase 17 U/L. Contrast-enhanced dynamic computer tomography analyses of aortic dissection or other surgical disorders were performed, and the results disclosed gastric antrum and colon herniation at the posterior mediastinum(Fig. 2). Emergent operation for reduction of the incarcerated stomach and colon and repair of the PEH were performed immediately. He was admitted to the intensive care unit for postoperative observation and was referred to the ordinary ward in the next day. He was discharged 1 week later without any complication and was followed up at the surgical outpatient department. Most patients with PEH have minimal symptoms. Obstructive symptoms range from mild nausea, bloating, or postprandial fullness to acute distress with dysphagia and retching [1]. However, these symptoms are often nonspecific and do not lead the clinician to the make early diagnosis in the ED. Despite its limited information in diaphragmatic hernia, plain radiography is the first preferred diagnostic tool [2]. Paraesophageal hernia rarely features on a list of differential diagnoses of acute chest or epigastric pain. It could be treated as myocardial insult, and the outcome could be life-threatening [3]. Thus, it is easily missed when ED physicians did not maintain a high index of suspicion. Multislice thoracoabdominal computed tomography scan is a very useful and reliable tool for diagnosis and detecting complications [2]. It could also offer the clues for operation. Misdiagnosis or underdiagnosis can lead to severe complications such as gastric perforation or volvulus [3-5]. In this case, the intrathoracic bowel gas was not identified by the ED physician in the beginning, and the PEH with incarceration of stomach and colon is not expectable. Although watchful waiting is a reasonable alternative for the initial management of patients with asymptomatic or minimally symptomatic PEH, elective laparoscopic PEH repair or emergency surgery are still beneficial for a small portion of patients with PEH [6]. Parameswaran et al [7] reported that laparoscopic repair for patients with paraesophageal hiatus hernia is shown to be a safe and effective operation. But surgical repair of PEH provide excellent outcomes and have low complication rate compared with laparoscopic approach [8-10]. In our case, open repair of hernia with reduction of incarceration of stomach and colon was performed. No complication or recurrence was noted. Paraesophageal hernia is a disease with potential risk of emergency surgery. This case highlights the challenge that noncardiac chest pain presents to the ED physician. Correct diagnosis and treatment can prevent life-threatening complications.