Indian J Surg DOI 10.1007/s12262-014-1135-1
CASE REPORT
Gastric Gangrene Due to a Strangulated Paraesophageal Hernia—a Case report Abid Iqbal & Rakesh Naik & PK Mohanan
Received: 18 June 2014 / Accepted: 27 June 2014 # Association of Surgeons of India 2014
Abstract Paraesophageal hernias are considered to be benign entities which are usually managed conservatively. We present a case of a middle-aged male with no previous history of esophageal hernia who presented with acute chest and abdominal pain. The patient was diagnosed to have a type 2 paraesophageal hernia with gastro-thorax. Laparotomy was performed during which it was found that herniated segment of the stomach had strangulated and gangrenous. Thoracotomy was performed and gangrenous stomach segment resected. A roux-en-Y esophagojejunostomy was performed. Diaphragmatic defect was plicated. Patient recovered with adequate post operative support. A review of the literature revealed that paraesophageal hernias presenting as acute abdominal pain is a rare clinical entity and those with gastric gangrene is even rarer, with high mortality rates. We suggest that paraesophageal hernias require to be managed actively considering the seriousness of potential complications and the relative safety of newer elective surgical modalities. A high index of suspicion is needed in order to avoid missing this diagnosis in patients presenting with chest pain. Keywords Paraesophageal hernia . Gangrene . Gastrectomy . Strangulation . Hernia . Hiatal
Introduction Akerlund was the first to classify paraesophageal hernias as type 2 of hiatal hernias in 1926 [1]. Paraesophageal A. Iqbal (*) : P. Mohanan Department of Surgery, Government Medical College Thrissur, Thrissur, Kerala, India e-mail:
[email protected] R. Naik Department of Cardiovascular and Thoracic Surgery, Christian Medical College Vellore, Tamilnadu, Kerala, India
hernias are usually asymptomatic or sometimes may present with chronic non-specific symptoms like abdominal pain, early satiety, or dysphagia. Sometimes they may present as an acute emergency due to strangulation of a bowel inside. Such presentations are rare and associated with high levels of mortality. We present a case of a successfully treated strangulated type 2 paraesophageal hernia which had resulted in a gastric gangrene.
Case Report A 46-year-old male patient presented in the emergency department with complaints of diffuse, dull, and aching abdominal and chest pain for 3 days. Pain was mainly over upper abdomen and left side of the lower chest. Pain was aggravated with food intake but was relieved briefly with medications. He had complaints of nausea and breathlessness on lying on the right side for 3 days. Patient was evaluated for 2 days in a peripheral hospital and managed symptomatically prior to admission. He was being treated for type 2 diabetes mellitus for 10 years with oral hypoglycemic agents. There was no significant past history or family history. At presentation, patient was sick looking, tachypneic, and had tachycardia. Breath sounds were reduced on the left side. Cardiac apex shifted medially. Oxygen saturation was maintained with oxygen inhalation. Examination of abdomen was grossly normal. A chest X-ray was taken, which showed presence of bowel loops in the left hemithorax. An upper GI endoscopy performed prior to referral to our hospital reported inflamed stomach with dark fluid in the fundus, probably bile reflux gastritis. A Ryles tube was inserted which drained no fluid. After resuscitating the patient, a CT scan of the thorax and abdomen was performed. This showed bowel loops in the left hemithorax, mediastinal shift to right, and free fluid in the
Indian J Surg
hernial sac. Features were suggestive of a paraesophageal hernia with organo axial volvulus (Fig. 1). An exploratory laparotomy was performed which showed edematous intraperitoneal portion of the pyloric antrum, but the proximal stomach was herniating to the thorax. On attempts to reduce hernia, toxic fluid was drained out. Laparotomy incision was extended to open left thoracic cavity in the 10th ICS. The hernial sac was opened. The fundus and proximal body of the stomach was found to be strangulated and gangrenous. A total gastrectomy was performed and Rouxen-Y esophago-jejunostomy was performed (Fig. 2). Diaphragmatic defect was repaired with polypropylene sutures. The wound was closed with tube thoracostomy. Patient recovered over time with supportive care. Oral feeds were started 10 days after verifying anastomotic integrity with contrast study.
Discussion Henry Ingersol Bowditch first reported 3 cases of paraesophageal hernia in a review of all diaphragmatic hernia reports published between 1610 and 1846 [2]. Esophageal hernia occurs when the anterior wall of the stomach herniate into the potential space between the esophagus and the phrenoesophageal ligament due to weakening of the pleuroperitoneal membrane. It is speculated that developmental abnormality, combined with a basic defect in the collagen/ elastin integrity of the individuals, may lead to the development of type 2 paraesophageal hernias [3]. Several anecdotal reports of strangulated paraesophageal hernias are seen in the literature. Sihvo et al. reported 5 cases of strangulated paraesophageal hernia causing death in a population-based study between 1987 and 2001 [4]. Ozdemir reported 2 cases of strangulated paraesophageal hernia which resulted in
Fig. 2 Gastrectomy specimen
gastric gangrene [5]. Bawhab et al. reported one case with perforation and mediastinitis in a series of 20 cases of complicated paraesophageal hernia [6]. Since the wake of availability of imaging studies, a number of asymptomatic paraesophageal hernias are being detected. Hence, a debate on whether to treat an asymptomatic patient is still active. Skinner and Belsey reported a high mortality of 29 % in expectantly managed asymptomatic paraesophageal hernia and recommended elective repair [7]. Tracey et al. reported that 45 % of expectantly managed patients ultimately required some indication, though none developed strangulation. The recently published SAGES guidelines recommends repair of all symptomatic paraesophageal hernias [8]. It recommends limited resection in cases involving gastric perforation. Due to their rarity and confusing symptomatology, they are often misdiagnosed unless a high index of suspicion is maintained. They should be considered as a differential diagnosis of chest pain if at least when common ones are ruled out.
Conclusion We report a case of a successfully treated strangulated type 2 paraesophageal hernia which had resulted in gastric gangrene. Considering the morbidity and mortality of doing an emergency procedure in a patient like ours against the safety of a minimally access planned repair, we believe it is reasonable to suggest an elective repair in asymptomatic patients with type 2 paraesophageal hernia. We wish to highlight the presentation and the need to keep a high index of suspicion to diagnose this rare albeit dangerous condition with minimal delay.
References
Fig. 1 CT
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