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Home , Hiatal Hernia, Inguinal hernia

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Case Report *Corresponding author Aleksandar Resanovic, Clinical Hospital Center Bezanijska Kosa, Hercegovacka 52b street, Belgrade, Large Hiatal Remain 11080, Republic of Serbia, Europe, Tel: 381604646011; Email: Submitted: 03 March 2017 a Challenging Condition in Accepted: 14 May 2017 Published: 31 May 2017 Clinical Practice Copyright © 2017 Resanovic et al. Aleksandar Resanovic1*, Vladimir Resanovic2, Milan Gojgic1, OPEN ACCESS Miroslav Djordjevic1, Mazen Arafeh3, and Aleksandra Aleksic1 1Clinical Hospital Center Bezanijska Kosa, Europe Keywords 2Emergency Center, Clinical Center of Serbia, Europe • Sliding hiatus ; Bleeding; Cardiorespiratory 3Cocoona Centre for Aesthetic Transformation, UAE difficulties;

Abstract Hiatus hernia is a very common condition in elderly patients. Most common type is sliding hiatus hernia (type I) with incidence of up to 95% of all hiatus hernias. Although, they are ussualy asymptomatic, several complications can occur from gastroesophageal reflux to bleeding as the most severe . An 81-year old male was admitted to the emergency department with , general weakness and dyspnea and of mitral valve replacement, a trial fibrillation and absolute ventricular arrhytmia, as well as chronic obstructive pulmonary dissease. Urgent upper GI showed two ulcers of the distal , as well as a hyperemic, edematous mucosa of proximal probably as a result of local stasis. Additional contrast radiography showed a large axial hiatus hernia, which constituted of 2/3 of the stomach in the . CT scan of thorax and confirmed previous findings, with the additional finding of a supressed heart and lungs and consequentiall bilateral pleural effusions. Although bleeding was stopped with conservative therapy, cardiorespiratory difficulties remained. Patient underwent open transabdominal hiatal which included retraction of the stomach back into the abdomen, closure of the hiatal pillars and a Nissen fundoplication. Besides an episode of transient anxiety and agitation, postoperative course was uneventful. Patient was discharged from hospital on the 9th postoperative day. Although the asymptomatic sliding hernia does not necessery require surgical treatment, if severe complication such as bleeding and worsening of cardiorespiratory comorbidity occurs, surgery must be done without any further delays.

INTRODUCTION obstructive pulmonary dissease. Also, several years before, the patient underwent right hernia repair and open The incidence of hiatus hernia rises with age [1]. Given the cholecystectomy. rising demographics and the growing number of , this condition now constitutes an increasingly common endoscopic incidence of up to 95% of all hiatus hernias, while different forms On admission, showed tender, painless finding. Most common type is sliding hiatus hernia (type I) with abdomen and melena during rectal exam, blood presure of Although they are typically asymptomatic, several complications 130/65 mm Hg, tachycardia (132 beats/min) and dyspnea. od paraesophageal hernias are less common (type II, III, and IV). Blood tests showed haemoglobin (Hgb) level of 129 g/L, INR level of 2,01, and signs of dehidration (low levels of basic serum chroniccan occur bleeding including [2]. Several gastroesophageal cases were reported reflux in disease, which large iron electrolytes - sodium 130 mmol/L and chloride 94,2 mmol/L, hiatusdeficiency hernias anemia, were ulcercompromising or erosion cardio formation, respiratory and acutefunction, or while potassium level was normal), and electrocardiogram showed atrial fibrilation and absolute arrhytmia. and they were misdiagnosed [3-5]. which showed two ulcers of the distal esophagus, as well as a We present a case of large sliding that was causing hyperemic,The patient edematous underwent mucosa of urgent stomach upper probably GI endoscopyas a result of local stasis. There was a suspicion on sliding hiatus hernia, comorbidity. but it could not be clear because of much undigested food in bleeding from the upper GI and worsening cadiorespiratory CASE REPORT or liver dissease. With the oral intake suspension, rehidration stomach. No anamnestic data were provided about alcohol abuse An 81-year old male was admitted to the emergency bleeding stopped, but in spite of antiarrhythmic, ß-blocker and with intravenous cristaloid sollutions and PPI therapy, the with history of 48h of melena, general weakness and dyspnea withoutdepartment abdominal with clinical pain. signs of upper GI bleeding, presented Additional diagnostics were done. Barium contrast radiography brochodilator therapy, cardiorespiratory difficulties remained. comorbidity because of mitral valve replacement, atrial showed a large axial hiatal hernia, which constituted of 2/3 of Medical history was significant for cardiopulmonary the stomach in the mediastinum. CT scan of the thorax and the abdomen corroborated previous findings, with the additional fibrillation and absolute ventricular arrhytmia, as well as chronic finding of a supressed heart and lungs and consequentiall Cite this article: Resanovic A, Resanovic V, Gojgic M, Djordjevic M, Arafeh M, et al. (2017) Large Hiatal Hernias Remain a Challenging Condition in Clinical Practice. JSM Gen Surg Cases Images 2(3): 1029. Resanovic et al. (2017) Email:

Central Bringing Excellence in Open Access bilateral pleural effusions. Heart revealed moderate aortic valve stenosis, hypertrophy of ventrucular walls, inreased right atrial pressure and preserved global ejection fraction of

55%. Indication for surgery treatment of hiatal hernia was made. hiatal hernia repair was made, which included retraction of the stomachAfter backadequate into preoperativethe abdomen, treatment, closure of openthe hiatal transabdominal pillars and a Nissen fundoplication. generalIn the anestesia early in postoperative elderly patients. course, Futher there postoperative was an episode course wasof transient uneventful. anxiety Gradually, and agitation oral intake as awas known established consequence with no of Figure 2 Contrast barium study indicating a large hiatal hernia. Green arrow symptoms. A control barium study showed clean passage of the is indicating hiatal opening of the diaphragm, red arrow indicates the part of signs of recurrent upper GI bleeding, and with no maldigestion stomach which has herniated to the mediastinum, and the blue arrow indicates With regular bronchodilator therapy, the symptoms diminshed, esophagogastric junction. bilateralcontrast into pleural the , effusion withdrew, and confirmed while clinical the registered findings. arrythmia was under control with antiarrhytmic and ß-blocker therapy. The patient was discharged on the 9th postoperative type with the incidence of up to 95%, and is often asymtomatic. day. Type I or sliding – axial hiatus hernia is the most common

DISCUSSION But when symptoms occur, gastroesophageal reflux is the most butcommon can occur one. inIt paraesophagealis important to pointtypes outof hernia that gastroesophageal as well. Bleeding fromreflux thedisease herniated (GERD) fundus is more of common the stomach, in sliding can hiatal lead hernia, to the The first report of hiatal hernia was published in 1853 by formation of mucosal ulcers, known as Cameron lesions that can Bowditch. Rokitansky in 1855 demonstrated that was livedue patient,to gastroesophageal and Friedenwald reflux, and and Feldman Hirsch relatedin 1900 the diagnosed symptoms an hiatal hernia using x-rays. Eppinger diagnosed a hiatal hernia in a suchproduce as iron-deficiency postprandial chestanemia. pain, Regardless postprandial of mechanism, fullness, many and shortnesspatients with of breath. hiatus herniaFinally, have in some other cases, non-specific the patient symptoms, can be to the presence of a hiatal hernia. In 1926, Akerlund proposed presented with an acute surgical condition, which is caused by the term hiatus hernia and classified them into the 3 types [6]. strangulation of the stomach from acute gastric . These According to SAGES (Society of American Gastrointestinal and patients retch but cannot vomit, and a nasogastric tube cannot Endoscopic Surgeons) [7], today there are 4 types: be passed into the stomach [8]. Also, giant hiatus hernias can through the hiatus; • type I: sliding HH-axial ascension of the gastric cardia worsen cardiac and respiratory function, especially in patients with cardiorespiratory comorbidity [9]. fundus past a normally positioned cardia; • type II: para-esophageal HH-upward rolling of the gastric The diagnosis of hiatal hernia can be made through radiographic, endoscopic and manometric assessment. Whereas esophageal rolling of the fundus; large hiatal hernias can be detected and diagnosed without • type III: mixed HH- ascension of the cardia plus para- hiatal hernias can be challenging with each modality having its upward by by the herniated gastric fundus or some other limitations.difficulty using Additionaly, either CTof scanthese may methods, be done diagnosing if complications small • abdominaltype IV: herniationorgan. of the transverse colon drawn occur [10]. Bleeding complications arise in 1/4 of patients with

hiatal hernia and GERD, and cause up to 10% of all acute and 1/3 ulcers,of all chronic erosive foregut esophagitis, bleedings. esophageal Most common ulcers, bleeding peptic stricturesdisorders anddirectly Barrett related esophagus to hiatal [2]. hernia and GERD are: hiatal hernia The presence of hiatus hernia is not an indication for treatment, and therapy should be given to patients with

common clinical manifestation in patients with hiatal hernia, symptoms attributable to this condition. Since GERD is the most

lifestyle modifications (, elevation of head in supine Figure 1 position, etc.) should be encouraged and (antacids, prokinetics, H2-receptor antagonists and proton pump inhibitors) CT of the thorax with green arrow pointing to the stomach that has suppression using proton pump inhibitors being the cornerstone points out the pleural effusion. herniated to the mediastinum (with dimensions stated), while the red arrow ofshould therapy first [11]. be prescribed to the symptomatic patients, with acid

JSM Gen Surg Cases Images 2(3): 1029 (2017) 2/3 Resanovic et al. (2017) Email:

Central Bringing Excellence in Open Access Unlike paraesophageal hiatal hernias that need surgical repair even in the absence of symptoms due to its potential for 2016. missed diagnosis of in the emergency room. BMJ Case Rep. development of complications such as bleeding, incarceration, 4. obstruction and perforation, isolated sliding hiatal hernias Fisichella. 2015; PM, Ramirez M, Patii MG. An underappreciated cause of intermittent chest pain, asthma, and iron deficiency anaemia. Dig 5. itself usually do not require surgical treatment [8]. However, Liver Dis 47: 897. mimicking as cardiac mass. Acute Card Care. symptomssurgical therapy based on (either the generally open or accepted laparoscopic) indications could for be antire given Palios J, Clement Jr S, Lerakis S. Chest pain due to hiatal hernia to hiatal hernia patients with severe and refractory GERD 6. 2014; 16: 88-89. Stylopoulos N, Ratner DW. The history of Hiatal hernia surgery form flux surgery: poor compliance to long-term medical therapy, Bowditch to . Annals of Surgery. 2005; 241: 185-193. requirement of high doses of drugs and young patients wishing patients can also resort to surgery if they develop complications 7. Society of American Gastrointestinal and Endoscopic Surgeons to avoid lifetime medical treatment. In addition, hiatal hernia such as recurrent bleeding, ulcerations, strictures, etc [12,13]. 8. (SAGES). Guidelines for the Management of Hiatal Hernia. 2013. Surgical management should envelope both the correction of Lebenthal A, Waterford SD, Fisichella PM. Treatment and controversies hiatal hernia by restoring the intra-abdominal esophagus and 9. in paraesophaeal hernia repair. Front Surg. 2015; 2: 13. reconstructing the diaphragmatic hiatus, and reinforcement of Matar A, Mroue J, Camporesi E, Mangar D, Albrink M. Large Hiatal 10. Hernia Compressing the Heart. Am J Cardiol. 2016; 117: 483-484. the LES by antireflux procedure with Nissen fundoplication being 601-616.Kahrilas P, Kim H, Pandolfino J. Approaches to the Diagnosis and theREFERENCES most frequently employed measure [8]. Grading of Hiatal Hernia. Best Pract Res Clin Gastroenterol. 2008; 22: 11. 1. Bak YT. Management strategies for gastroesophageal reflux disease. J Sleisenger MH, Feldman M, Friedman LS, Brandt LJ. Sleisenger and 12. Gastroenterol , Hepatol. ,2004; á 19:cov á49-53., Tycov á , Siroký , á Fordtran’s gastrointestinal and : Pathophysiology, et al. Hiatal hernia and Barrett’s oesophagus impact on symptoms diagnosis, management. 9th ed. Philadelphia, PA: Saunders, Elsevier. Al-Tashi M Rejchrt S Kop M . V M Rep k R, 2. 2010:Simi 381-383, 710. O, 13. occurrence and complications. Cas Lek Cesk 2008; 147: 564-568. ć A, Radovanović N, Kotarac M, Gligorijević M, Skrobić KonstantinovićV, et al. Hiatal hernia of the esophagus and GERD as a Siu CW, Jim MH,. Ho HH, Chu F, Chan HW, Lau CP, et al. Recurrent acute 3. cause of hemorrhage. Acta Chir Iugosl. 2007; 54: 135-138. heart failure caused by sliding hiatus hernia. Postgrad Med J. 2005; 81: 268-269 Ghosh KR, Fatima K, Ravakhah K, Hassan C. : an easily

Cite this article Resanovic A, Resanovic V, Gojgic M, Djordjevic M, Arafeh M, et al. (2017) Large Hiatal Hernias Remain a Challenging Condition in Clinical Practice. JSM Gen Surg Cases Images 2(3): 1029.

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