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Interesting Case Rounds

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

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Interesting Case Rounds

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  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, SpO2 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 <40 and 70% 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. Hiatal Hernia

  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 = Borchart’s 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

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