Paraesophageal Hernia as a Cause of Chronic Asymptomatic Anemia in a 6 Years Old Boy; Case Report and Review of the Literature

Giant hiatal hernia with intrathoracic spleen: A case report

Hiatal hernia is a frequent pathology in the population; however, the most frequent hiatal hernia is type I, which accounts for up to 95% incidence, types II, III, and IV being less frequent and representing between 5% and 15%, and even less common are giant hernias. The definition of the giant hernia is still not exact in the literature; some authors define giant or massive hiatal hernia as one in which the hernia occupies more than 30% of the stomach and/or passes from other abdominal structures to the thorax. We describe the case of a patient with gastrointestinal symptomology without response to a proton pump inhibitor, with base exacerbation that required imaging studies, showing a large hernia defect passing to the thorax from abdominal organs (stomach, spleen, mesenteric fat), as well as alteration of the gastric and spleen axis with ascent in pancreatic body and tail, which corresponds to a giant hiatal hernia. Said pathology is very infrequent, with recurrences and postoperative complications. Our patient recovered from the surgical procedure with therapeutic success.

Towards a better diagnosis of gastro esophageal reflux disease

INTRODUCTION

GERD is a common disorder and is characterized by the presence of typical or atypical symptoms. In GERD patients, the presence of mucosal alterations in endoscopy is detected in up to 30% of individuals. The clinical presentation of GERD patients may be complex and their management is challenging, due to the heterogeneous clinical presentation. The present review has been performed searching all relevant articles in this field, over the past years, using PubMed database.

AREAS COVERED

The diagnosis and management of GERD have been significantly improved in the last years due to the increasing availability of reflux monitoring techniques and the implementation of new procedures in the therapeutic armamentarium. Beside traditional impedance-pH variables, new metrics have been developed, increasing the diagnostic yield of reflux monitoring and better predicting the treatment response. Traditional pharmacological treatments include acid-suppressive-therapy and/or anti-acid. On the other hand, surgical treatment and, more recently, endoscopic procedures represent a promising field in the therapeutic approach.

EXPERT OPINION

Diagnosis and treatment of GERD still represent a challenging area. However, we believe that an accurate upfront evaluation is, nowadays, necessary in addressing patients with GERD to a more accurate diagnosis as well as to the best treatment options.

Late presentation of congenital type IV esophageal hiatus hernia in a 9-year-old boy: a case report

Background

Congenital diaphragmatic hernia affects 1 in every 2000–5000 live births. The mediastinum shifts to the opposite side, the lungs are hypoplastic, and the arterioles are abnormal, resulting in pulmonary hypertension. Respiratory and cardiovascular functions are severely impaired at birth, resulting in significant mortality and morbidity as a result of the associated malformations.

Case presentation

A 9-year-old persian boy was referred with complaint of intermittent abdominal pain in the left lower quadrant and an episode of vomiting. The patient was tachypneic, and the abdomen was nontender on examination. Lung sounds on the left side were considerably decreased, whereas heart sounds on the right side were louder. There was no history of underlying disease in the patient. Initial laboratory blood tests, chest x-ray, spiral computed tomography scan, and chest sonography were requested. Blood tests were normal, and chest x-ray revealed a round-shaped lesion with relatively clear boundaries containing air–fluid level and shift of the heart and mediastinum to the right. A spiral computed tomography scan of the lungs demonstrated the shift of the heart and mediastinum to the right side was due to dilated stomach and colon pressure, and chest sonography revealed that half of the stomach was inside the thorax. Laparotomy surgery was performed. The patient had no complications following surgery.

Conclusions

Herniation of abdominal contents through the diaphragmatic hiatus should be suspected in patients with tachypnea and mediastinal shift to the right side. Rapid diagnosis and early surgical treatment are necessary to avert any potentially life-threatening complications.

Contrast-enhanced ultrasound using SonoVue mixed with oral gastrointestinal contrast agent to evaluate esophageal hiatal hernia: Report of three cases and a literature review

BACKGROUND

Due to a thicker abdominal wall in some patients, ultrasound artifacts from gastrointestinal gas and surrounding tissues can interfere with routine ultrasound examination, precluding its ability to display or clearly show the structure of a hernial sac (HS) and thereby diminishing diagnostic performance for esophageal hiatal hernia (EHH). Contrast-enhanced ultrasound (CEUS) imaging using an oral agent mixture allows for clear and intuitive identification of an EHH sac and dynamic observation of esophageal reflux.

CASE SUMMARY

In this case series, we report three patients with clinically-suspected EHH, including two females and one male with an average age of 67.3 ± 16.4 years. CEUS was administered with an oral agent mixture (microbubble-based SonoVue and gastrointestinal contrast agent) and identified a direct sign of supradiaphragmatic HS (containing the hyperechoic agent) and indirect signs [e.g., widening of esophageal hiatus, hyperechoic mixture agent continuously or intermittently reflux flowing back and forth from the stomach into the supradiaphragmatic HS, and esophagus-gastric echo ring (i.e., the “EG” ring) seen above the diaphragm]. All three cases received a definitive diagnosis of EHH by esophageal manometry and gastroscopy. Two lesions resolved upon drug treatment and one required surgery. The recurrence rate in follow-up was 0%. The data from these cases suggest that the new non-invasive examination method may greatly improve the diagnosis of EHH.

CONCLUSION

CEUS with the oral agent mixture can facilitate clear and intuitive identification of HS and dynamic observation of esophageal reflux.

The management of hiatal hernia: an update on diagnosis and treatment

Background and aim

Hiatal hernia (HH) occurs quite frequently in the general population and is characterized by a wide range of non-specific symptoms, most of them related to gastroesophageal reflux disease. Treatment can be challenging at times, depending on the existence of complications. The most recent guideline regarding the management of hiatal hernia was released by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in the year 2013. This review aims to present the most recent updates on the diagnosis and management of hiatal hernia for clinical practitioners.

Methods

The PubMed database was screened for publications using the terms: “hiatal hernia”, “paraesophageal hernia”, “management”, “treatment”, “hiatal repair”. A literature review of contemporary and latest studies was completed. The studies that we looked into include prospective, randomized trials, systematic reviews, clinical reviews and original articles. The information was compiled in narrative review format.

Results

This narrative review presents new data on the diagnosis and management of hiatal hernia. While the diagnostic pathway has remained virtually unchanged, new data have come to light regarding the surgical treatment of hiatal hernia. We present the imaging methods used for its diagnosis, as well as the medical and surgical treatment currently available.

Conclusion

In the last five years, there has been vast research in the field of hiatal hernia management, especially regarding the surgical treatment. However, unanswered questions still remain and solid updates on the guidelines have yet to be formulated. To address this, more randomized studies need to be done on subsets of patients, stratified by age, gender, symptoms and comorbidities.