Background

Para-oesophageal (rolling) hiatus herniae are less common than sliding hiatus herniae. They are more common in the elderly age group. Often asymptomatic, they may present with dysphagia, chest pain and a gastro-oesophageal reflux picture. The symptoms are thought to be due to twisting and distortion of the oesophagus and stomach. The hernia is usually present on a plain chest radiograph as an intra-thoracic gas bubble, often with a fluid level behind the heart. The investigation of choice is usually a barium swallow. Because of the higher risk of complications with these herniae surgery is often indicated. Operative management can involve either thoracic or abdominal open approach, or may involve a laparoscopic repair with a fundoplication (₁).

This case report describes an elderly lady who presented with an acute abdomen caused by a perforated strangulated para-oesophageal hiatus hernia.

Case Report

An 88-year-old female presented acutely to the on call surgical team with abdominal pain. This had started over the previous 36-48 hours and had been accompanied by vomiting and anorexia. Her past medical history included myocardial infarction, cerebrovascular disease, hypertension and arthritis, she denied any previous gastrointestinal pathology. On examination she was extremely unwell, with hypotension, tachycardia, tachypnoea and oliguria. Examination of the abdomen revealed generalised peritonism, with widespread guarding and rigidity on examination of her abdomen. Her erect chest x-ray is pictured below. Of note from her blood results were a moderate rise in amylase, and a large rise in white cell count. The decision was made to take her to theatre for a laparotomy, with a provisional diagnosis of perforated intra-abdominal viscous.

On entering the peritoneum, there were widespread upper GI contents freely floating around. Examination of the viscera revealed a large strangulated para-oesophageal hiatus hernia, which had not been evident from the initial presentation, or from the chest x-ray. On reduction of the hiatus hernia, a large perforation was found on the posterior aspect of the fundus. Due to the patient's frailty and poor overall condition, the defect was closed directly with interrupted sutures and the stomach was plicated around it. An omental patch was sutured over the area. The stomach was anchored to the diaphragm with interrupted sutures to prevent recurrence of the hernia. A drain was inserted and a feeding jejunostomy was sited. The patient was transferred to the intensive care unit. Over the subsequent post-operative period the patient developed worsening multi-organ failure, and then several days later she passed away.

Figure 1

Figure 1: Plain erect chest radiograph taken on admission of the patient

Conclusion

Acute abdominal pain is a rare presentation of a strangulated para-oesophageal hiatus hernia. A systematic search of Pubmed was performed, the key words used were; strangulated, perforated and hiatus hernia. This search revealed only one case report of a strangulated perforated para-oesophageal hernia presenting with acute abdominal pain (₂). This case report was in Italian, there were no reported cases of this condition in English.

The above case describes an atypical presentation of a para-oesophageal hernia, in both history and examination, and also in radiological findings. Although rare, it is important to consider this condition as a possible cause of the acute abdomen.

Competing interests

Corresponding author

Mr IE Katsoulis (hrkats@yahoo.ac.uk) Department of General Surgery Watford General Hospital 60, Vicarage Road Watford Hertfordshire WD18 0HB United Kingdom