1. + Interesting Case Rounds Yael Moussadji, R5 July 24, 2008

2. + 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)

3. + Case P/E Alert Afebrile, HR 112, BP 155/85, SpO 2 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

4. + Differential Diagnosis of Chest Pain Cardiac Vascular Pulmonary GI MSK

5. + Investigations Labs ECG CXR

6. + CT chest

7. + Barium Swallow

8. + 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 70

9. + 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

10. + Types Type III - Mixed Mixed sliding and paraesophageal component Largest group of patients with paraesophageal hernias Type IV - Complex Involves spleen, liver, colon

11. + Types of Hiatal Hernias

12. + 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

13. + Hiatal Hernia

14. + 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

15. + Paraesophageal hernia (Type II)

16. + 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

17. + 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

18. + Imaging Barium Upper GI Series Endoscopy CT chest

19. + Hiatal Hernia

20. +

21. + 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)

22. + 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

23. + 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 = Borcharts 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

24. + Gastric Volvulus: Management Goal of treatment is reduction Attempt passage of an NG to decompress stomach, which may reduce volvulus Endoscopic reduction or surgery

25. + 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