Introduction:
A hiatal hernia (HH) is a well-known structural pathology found in approximately 30-50% of the western population. A complex type IV HH is a rare, representing 0.1% of HH cases. This unique case report explores the presentation of a 76-year-old man with a partial bowel obstruction secondary to a complex type IV HH.
Case:
A 76-year-old male presented three time over nine days to the GP with complaints of progressively worsening abdominal distention associated with nausea, vomiting, dull epigastric pain, several days of constipation with one small episode of overflow diarrhea. Significant comorbid background history included ischemic heart disease, hypertension, type two diabetes, obstructive airway disease, reflux disease, colorectal cancer with open bowel resection and left elevated hemi diagram. On examination the patient was hemodynamically stable but clinically dehydrated. Abdominal examination found a large ventral hernia (10cm by 14cm), situated midline in the epigastric region behind laparotomy scar. The abdomen was distended with tenderness on palpation of the epigastric region, bowel sounds were high pitch and tinkling. There were no signs of peritonism. Outpatient CT scan found large diaphragmatic hernia measuring 14.7cms anteroposterior with herniation of entire stomach, entire spleen, large amount of mesenteric fat, part of pancreas, part of the left kidney, entire left adrenal, splenic flexure region and proximal descending colon into the left hemithorax causing compressive atelectasis of the lingula and left lower lobe with partial bowel obstruction secondary to mass compression. The patient was sent to the emergency department and admitted under the acute surgical team for conservative management of partial bowel obstruction. Post discharge he was follow up with an upper GI surgeon for ongoing review.
Discussion and key learning points:
Complex type IV HH is characterised by a defect in the diaphragmatic hiatus with the presences of structures other than the stomach such as, omentum, colon, small intestines and other abdominal organs within the thoracic cavity. They occur due to a large defect in the pharyngoesophageal membrane, as well as an increased laxity in the oesophageal hiatus, providing more area for organ protrusion. They can be on occasions be asymptomatic, present clinically with regurgitation, reflux disease, postprandial breathlessness, early satiety and dysphagia. There are multiple diagnostic techniques that are of use in diagnosing hiatal hernias. Barium swallow radiography provides important details of the upper gastrointestinal tract, including insight of disease pathology, in this case, the size of the herniated portion of the stomach as well as the position of the GE junction. Additionally, CT scans are useful in visualization of hiatal hernias and provide valuable information on the type of hiatal hernia and involved organs. These types of hernias while very rare can lead to life threatening complications such as bowel obstruction, volvulus, ischemic bowel, perforation, sepsis and death. Elective repair of such hernias is advocated for early to prevent acute life-threatening complications.