Hiatal hernia complicated by gastric ulceration and perforation

Spontaneous Mediastinal Gastric Perforation in Hiatal Hernia with Difficult Surgical Technique Selection: A Case Report

Emergency surgery for a hiatal hernia (HH) is uncommon. However, mediastinal gastric perforation may occasionally present as the initial symptom of HH and demonstrate high mortality rates. Managing mediastinal gastric perforation in HH has no established standard surgical technique, and the selection of surgical techniques may be challenging. A 78-year-old female patient was referred to our department because of an upper gastrointestinal perforation in HH based on computed tomography (CT) results. Determining the possibility of esophageal perforation and intrathoracic penetration was difficult according to CT results alone, and whether a transthoracic or transabdominal approach was preferable. We diagnosed the patient with a mediastinal gastric perforation in HH without intrathoracic penetration based on an additional gastrointestinal contrast study and a right thoracentesis. We treated the patient with laparotomy, involving the perforation site and esophageal hiatus closure and gastropexy. Postoperatively, the patient experienced complications associated with delayed gastric emptying and aspiration pneumonia. Fortunately, no severe infections, such as residual abscess formation or empyema, were observed, and the recovery progressed favorably. Mediastinal gastric perforation should be considered a differential diagnosis for elderly patients with sudden-onset chest pain and dyspnea, and the threshold for imaging should be lowered. Identifying the perforation site and the presence of intrathoracic penetration based on preoperative results is useful for determining the appropriate surgical technique. Postoperative quality of life to the extent feasible needs to be considered, as the selection of surgical technique may cause subsequent recurrence or reflux symptoms.

A case of conservatively managed gastric perforation at a recurrent hiatal hernia site after laparoscopic paraesophageal repair

INTRODUCTION AND IMPORTANCE

Gastric perforation due to a hiatal hernia is a rare cause of acute abdominal pain that often requires surgical intervention. Conservative management for this condition is an effective option in certain cases, although fewer reports of this exist. Herein, we report a unique case of gastric perforation caused by a recurrent hiatal hernia that was successfully treated with conservative management.

CASE PRESENTATION

A 74-year-old man developed a high fever and an elevated inflammatory response on the third day after a laparoscopic paraesophageal hernia repair using a mesh. Computed tomography confirmed the recurrence of the hiatal hernia, with gastric fundal prolapse into the mediastinum and surgical emphysema in the gastric wall. This was followed by a gastric perforation within the mediastinum. The patient was treated using an ileus tube through the perforation site.

CLINICAL DISCUSSION

In similar cases, if the clinical symptoms are mild, there are no signs of serious infection, and the perforation remains in the mediastinum and can be appropriately drained, conservative treatment is considered an option.

CONCLUSION

Under favorable conditions, conservative management can be an option for gastric perforation in patients with recurrent hiatal hernias, which is a serious potential postoperative complication.

Rare case of high amylase pleural effusion without pancreatitis, oesophageal rupture or malignancy

High amylase pleural effusion remains an entity which includes a wide variety of differentials, with pancreatitis, oesophageal rupture or malignant pleural effusion being most commonly encountered in clinical practice. Keeping the clinical picture (suggestive of pain in abdomen preceding any respiratory complaints) and differentials at hand, the case was evaluated with contrast-enhanced CT of the thorax and abdomen which revealed normal pancreatic architecture and no abnormal communication was noted between the pancreas and pleural space. A contrast oesophagogram, done when pancreatitis was ruled out, showed no evidence of any leak. The patient underwent upper gastrointestinal endoscopy which was suggestive of an ulcer with fistulous communication with the pleural space. Following nasojejunal feeding and clipping of the fistulous tract the patient's symptoms improved.

Hiatal Hernia With Gastric Perforation

A 63-year-old male with a history of hiatal hernia presented with one day of hematemesis and acute peritonitis. Computed tomographic imaging revealed perigastric pneumoperitoneum concerning perforated viscus. Exploratory laparotomy revealed a Type III hiatal hernia with a perforated posterior gastric ulcer, which was reduced and repaired. This report describes a case of acute abdomen secondary to hiatal hernia, a rare presentation of hiatal hernia, along with its surgical management and postoperative care.

Pleural effusions of extravascular origin

Most pleural effusions are caused by hydrostatic and oncotic pressure imbalance, inflammation or infection, or abnormalities in lymphatic drainage. A select number of effusions are caused by fluid of extravascular origin. Some of these effusions result from complications of treatment, whereas others are a ramification of the underlying disease. The incidence, pathogenesis, clinical presentation, chest radiographic manifestations, pleural fluid analysis, diagnosis, and management are discussed.

Oesophageal hiatal hernia-induced hydropneumothorax

The patient presented with acute and constant abdominal pain. He had had a lobectomy of the left lung three months before. On the 4th day in hospital the pain increased and he went into temporary shock. The next day a hydropneumothorax and incarcerated stomach were revealed by chest X-ray and computed tomography. He was transferred to the University Hospital immediately and underwent an operation. The diagnosis was an incarcerated para-oesophageal hernia with hydropneumothorax and perforation of the stomach. As a para-oesophageal hernia may be fatal, it is important to diagnose and treat it early.