Abstract | April 20, 2023
Respiratory decompensation masquerading Hiatal Hernia and Gastric Volvulus
Learning Objectives
- Describe hiatal hernia as a condition that causes upper part of the stomach, located below the diaphragm to bulge through the esophageal hiatus of the diaphragm into the thorax. In Type 1 hiatal hernia, the gastroesophageal junction slides along with a part of the stomach.
- Discuss that >95% of hiatal hernias are Type 1 and rarely cause symptoms except reflux. Rarely, respiratory symptoms can be observed in older patients. This is due to chemical irritation of the upper gastrointestinal tract which leads to micro-aspiration into the respiratory tract, especially in recumbent position. Additionally, a large hiatal hernia can cause an extrinsic obstruction of the airway and compression within the thorax, exacerbating respiratory symptoms as seen in this case.
- Diagnose large hiatal hernia in a patient mimicking cardiopulmonary disease related signs and symptoms like orthopnea, paroxysmal nocturnal dyspnea, acute type 1 respiratory failure.
INTRODUCTION: Common symptoms of hiatal hernia include epigastric or substernal pain or postprandial fullness, nausea, retching and acid reflux. The incidence of hiatal hernia presenting with only symptoms of dyspnea and orthopnea is reported to be unusual and is sparsely reported in the literature. Here we present one such case in which dyspnea was initially attributed to chronic obstructive pulmonary disease (COPD) and the diagnosis was revised during readmission.
CASE PRESENTATION: An 82-year-old female presented with a one-month history of exertional dyspnea and orthopnea. She had been a lifelong passive smoker and had worked in a sewing factory. On admission, her vitals were remarkable for hypoxia with saturation being 87% on room air. Physical exam revealed bilateral mild crepitation on chest auscultation. Lab investigations were unremarkable. Chest x-ray revealed cardiomegaly and a large hiatal hernia. CTA ruled out pulmonary emboli but revealed a large hiatal hernia and changes consistent with COPD. She was admitted with a diagnosis of COPD exacerbation and was managed with oxygen supplementation, steroids, breathing treatments, and antibiotics, with resultant improvement in symptoms and subsequent discharge from the hospital. Outpatient pulmonary function testing showed mild airflow obstruction. Three weeks later, she presented with worsening symptoms of orthopnea, frequent nighttime awakenings and throat clearing. On examination, vitals were significant for hypoxia with saturation 87% on room air. Cardiopulmonary exam revealed bilateral diffuse crackles. Lab investigations showed leukocytosis 12000/mm3, BNP 656. Chest x-ray revealed infiltrate involving right lung base and a large hiatal hernia. A coronary angiogram showed non-obstructive coronary artery disease without any evidence of heart failure.
Final diagnosis/Follow up: With this additional information, her diagnosis was revised to that of respiratory decompensation due to mechanical complication of large hiatal hernia, with possible nocturnal aspiration leading to chronic lung inflammation. She underwent upper gastrointestinal series which revealed a very large hiatal hernia without evidence of obstruction, partial organo-axial volvulus, and severe esophageal dysmotility. Management/Follow up: In view of increased risk for torsion and worsening volvulus, the patient was transferred to tertiary center for surgical evaluation.
References
Mirdamadi SA, Arasteh M. Hiatal hernia: An unusual presentation of dyspnea. N Am J Med Sci. 2010;2(8):395-396. doi:10.4297/najms.2010.2395
Unexpected cause of respiratory distress
Joana Sotto Mayor, Ana Lages, Sofia Esperança, Antonio Oliveira e Silvahttp://dx.doi.org/10.1136/bcr-2015-213408
Karan A, Guo HJ, Ng K, Izzo C. A Breathtaking Hernia: A Giant Hiatal Hernia Masquerading as Poorly Controlled Asthma. Cureus. 2022 Feb 16;14(2):e22268. doi: 10.7759/cureus.22268. PMID: 35350499; PMCID: PMC8933146
