American Journal of Therapeutics 0, 1–3 (2015)
It Is Not Always the Pulmonary Embolism Sepehr Daheshpour, MD* and Sundeep Shenoy, MD, FACP
One of the leading reasons for emergency department visits happens to be chest pain and shortness of breath with estimated 6.3 million visits for chest pain and 3 million visits for shortness of breath. Over the years, there has been an upward trend in these demographics. The primary workup is usually toward cardio pulmonary causes. Paraesophageal hernia is a term to describe the herniation of gastroesophageal junction and the gastric fundus through the paraesophageal membrane. Paraesophageal hernias account for 5% of all the hiatal hernias, and patients are usually asymptomatic or have complaints of gastroesophageal reflux. However, on rare occasions, they are notorious to develop complications such as incarceration, gangrene, obstruction of intrathoracic stomach, collapse of the lung, and even death. We take this opportunity to present a 49-year-old man who presented with shortness of breath and chest pain. The initial workup revealed a pulmonary embolism on a computerized tomography scan. However, with better clinical judgment and more imaging, he was diagnosed with a paraesophageal hernia with gastric obstruction and early strangulation causing his symptoms. Keywords: paraesophageal hernia, gastric obstruction, timing of surgery
CASE PRESENTATION We present a 49-year-old man who presented to the University Hospital with 2 days of pain in his left chest, midaxillary region, and the left infrascapular region. The pain was sudden in onset and was progressively worsening. The pain was pleuritic in nature and was associated with shortness of breath. His medical history was significant for Non-Hodgkin’s lymphoma, which was in remission. In the emergency department, he was noted to be in sinus tachycardia and in significant pain. A computerized tomography (CT) of the chest with contrast revealed a subsegmental pulmonary embolism (PE) in the left lower lobe (Figure 1). His symptoms were attributed to the PE, and treatment with intravenous
Department of Internal Medicine, University of Arizona, Tucson, AZ. The authors have no conflicts of interest to declare. *Address for correspondence: Department of Internal Medicine, University of Arizona, 1501 N. Campbell Avenue, PO Box 245212, Tucson, AZ 85724-5212. E-mail: sdaheshpour@ email.arizona.edu
heparin was initiated. The patient was admitted to the medical ward for further management.1–5 What was concerning in his clinical picture was that the nature of his pain and shortness of breath could not be explained by the small segmental PE in the peripheral branch for the left lower lobe. In addition to the small PE, the significant finding on the CT scan of the chest was that a large portion of the stomach had herniated in the left hemithorax (Figure 2). A CT scan of the abdomen was performed (Figure 3). This scan revealed not only the herniation of the fundus of the stomach but also showed moderate air–fluid levels in the stomach associated with significant adhesions, partial obstruction, and early strangulation (Table 1). This was the plausible explanation to his symptoms. General surgery was consulted, and the patient was taken to the operation theater for an urgent gastric decompression and Nissen fundoplication. Heparin drip was stopped 6 hours preoperatively and was re-initiated within 24 hours postoperatively. The patient developed pneumonia in the postoperative period, which was treated as a hospital-acquired pneumonia. Overall, the patient did well and was eventually discharged.
1075–2765 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.americantherapeutics.com
Copyright Ó 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
2
FIGURE 1. Coronal CT image demonstrating the paraesophageal hernia.
DISCUSSION Hiatal hernia is a very common clinical entity. Hiatal hernias can be broadly divided into sliding and paraesophageal hernias. Although the sliding hiatal hernia
Daheshpour and Shenoy
FIGURE 3. Axial CT image demonstrating stomach herniated through diaphragm into the thorax.
is the displacement of the gastroesophageal junction above the diaphragm, paraesophageal hernia is a true hernia with herniation of the fundus of the stomach through a defect in the diaphragm. Paraesophageal hernias account for 5% of all the hiatal hernias with their prevalence noted to be higher in the developed nations.6,7 Patient with paraesophageal hernia are usually older and the incidence increases with age. Patients with paraesophageal hernias can present with nonspecific symptoms such as gastroesophageal reflux symptoms or “heart burn.” Most of these symptoms usually managed conservatively with proton pump inhibitors. Other common symptoms include
Table 1. Key points.
FIGURE 2. Coronal CT image demonstrating stomach herinated through the diaphragm into the thorax. American Journal of Therapeutics (2015) 0(0)
Hiatal hernias can complicate and present with obstruction, strangulation, and volvulus. These are associated with high morbidity and mortality if not diagnosed early. A high degree of suspicion is required because in most cases the symptoms are nonspecific An urgent consultation with the surgical team would be the most appropriate next step in the management of a strangulated paraesophageal hernia There is no known medical therapy for the management of paraesophageal hernias. Symptomatic patients likely need surgical correction. Timing of this elective surgery is still debated www.americantherapeutics.com
Copyright Ó 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
It Is Not Always the Pulmonary Embolism
dysphagia, nausea and vomiting, coughing, and shortness of breath.8 Acute complications of paraesophageal hernia can be gastric volvulus with incarceration or strangulation. Gastric ischemia leading to perforation is the main cause of mortality when complications set in.9 Ozdemir reported 2 cases of strangulated paraesophageal hernia resulting in gastric gangrene.10 Sihvo et al11 reported 5 cases of strangulated paraesophageal hernia, which led to death in his population-based study between 1987 and 2001. There is no single mechanism that accounts for the development of paraesophageal hernia. Some of the proposed causes include shortened esophagus due to long-standing gastroesophageal reflux (GERD), imbalance between abdominal and intrathoracic pressures, age-related weakening of connective tissues, and imbalance of type 1 and type 2 collagen in the connective tissue of the hiatal orifice.9 Paraesophageal hernia is diagnosed using imaging or esophagogastroduodenoscopy. There is no medical treatment for a paraesophageal hernia, and symptomatic patients usually require surgical correction. The timing of this surgery still remains a debate. Most surgical corrections are now performed laparoscopically. Common things being common, a PE can cause chest pain and shortness of breath. However, anchoring of our diagnosis to this could have been detrimental to the patient. The importance of putting together all the pieces of a clinical presentation to avoid cognitive errors cannot be overstated.
www.americantherapeutics.com
3
REFERENCES 1. Pitts SR, Niska RW, Xu J, et al. National hospital ambulatory medical care survey: 2006 emergency department summary. Natl Health Stat Report. 2008;7:1–38. 2. Niska R, Bhuiya F, Xu J. National hospital ambulatory medical care survey: 2007 emergency department summary. Natl Health Stat Report. 2010;1–31. 3. Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophageal hernia repair. Arch Surg. 1997;132:586–589; discussion 590–591. 4. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22:601–616. 5. Marano L, Schettino M, Porfidia R, et al. The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia. BMC Surg. 2014;14:1. 6. Ilves R. Hiatus hernia. the condition. Chest Surg Clin N Am. 1998;8:401–409. 7. Burkitt DP. Hiatus hernia: is it preventable? Am J Clin Nutr. 1981;34:428–431. 8. Richter JE. Typical and atypical presentations of gastroesophageal reflux disease: the role of esophageal testing in diagnosis and management. Gastroenterol Clin North Am. 1996;25:75–102. 9. Collet D, Luc G, Chiche L. Management of large paraesophageal hiatal hernias. J Visc Surg. 2013;150:395–402. 10. Ozdemir IA, Burke WA, Ikins PM. Paraesophageal hernia. A life-threatening disease. Ann Thorac Surg. 1973;16:547–554. 11. Sihvo EI, Salo JA, Rasanen JV, et al. Fatal complications of adult paraesophageal hernia: a population-based study. J Thorac Cardiovasc Surg. 2009;137:419–424.
American Journal of Therapeutics (2015) 0(0)
Copyright Ó 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
It Is Not Always the Pulmonary Embolism Sepehr Daheshpour, MD* and Sundeep Shenoy, MD, FACP
One of the leading reasons for emergency department visits happens to be chest pain and shortness of breath with estimated 6.3 million visits for chest pain and 3 million visits for shortness of breath. Over the years, there has been an upward trend in these demographics. The primary workup is usually toward cardio pulmonary causes. Paraesophageal hernia is a term to describe the herniation of gastroesophageal junction and the gastric fundus through the paraesophageal membrane. Paraesophageal hernias account for 5% of all the hiatal hernias, and patients are usually asymptomatic or have complaints of gastroesophageal reflux. However, on rare occasions, they are notorious to develop complications such as incarceration, gangrene, obstruction of intrathoracic stomach, collapse of the lung, and even death. We take this opportunity to present a 49-year-old man who presented with shortness of breath and chest pain. The initial workup revealed a pulmonary embolism on a computerized tomography scan. However, with better clinical judgment and more imaging, he was diagnosed with a paraesophageal hernia with gastric obstruction and early strangulation causing his symptoms. Keywords: paraesophageal hernia, gastric obstruction, timing of surgery
CASE PRESENTATION We present a 49-year-old man who presented to the University Hospital with 2 days of pain in his left chest, midaxillary region, and the left infrascapular region. The pain was sudden in onset and was progressively worsening. The pain was pleuritic in nature and was associated with shortness of breath. His medical history was significant for Non-Hodgkin’s lymphoma, which was in remission. In the emergency department, he was noted to be in sinus tachycardia and in significant pain. A computerized tomography (CT) of the chest with contrast revealed a subsegmental pulmonary embolism (PE) in the left lower lobe (Figure 1). His symptoms were attributed to the PE, and treatment with intravenous
Department of Internal Medicine, University of Arizona, Tucson, AZ. The authors have no conflicts of interest to declare. *Address for correspondence: Department of Internal Medicine, University of Arizona, 1501 N. Campbell Avenue, PO Box 245212, Tucson, AZ 85724-5212. E-mail: sdaheshpour@ email.arizona.edu
heparin was initiated. The patient was admitted to the medical ward for further management.1–5 What was concerning in his clinical picture was that the nature of his pain and shortness of breath could not be explained by the small segmental PE in the peripheral branch for the left lower lobe. In addition to the small PE, the significant finding on the CT scan of the chest was that a large portion of the stomach had herniated in the left hemithorax (Figure 2). A CT scan of the abdomen was performed (Figure 3). This scan revealed not only the herniation of the fundus of the stomach but also showed moderate air–fluid levels in the stomach associated with significant adhesions, partial obstruction, and early strangulation (Table 1). This was the plausible explanation to his symptoms. General surgery was consulted, and the patient was taken to the operation theater for an urgent gastric decompression and Nissen fundoplication. Heparin drip was stopped 6 hours preoperatively and was re-initiated within 24 hours postoperatively. The patient developed pneumonia in the postoperative period, which was treated as a hospital-acquired pneumonia. Overall, the patient did well and was eventually discharged.
1075–2765 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.americantherapeutics.com
Copyright Ó 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
2
FIGURE 1. Coronal CT image demonstrating the paraesophageal hernia.
DISCUSSION Hiatal hernia is a very common clinical entity. Hiatal hernias can be broadly divided into sliding and paraesophageal hernias. Although the sliding hiatal hernia
Daheshpour and Shenoy
FIGURE 3. Axial CT image demonstrating stomach herniated through diaphragm into the thorax.
is the displacement of the gastroesophageal junction above the diaphragm, paraesophageal hernia is a true hernia with herniation of the fundus of the stomach through a defect in the diaphragm. Paraesophageal hernias account for 5% of all the hiatal hernias with their prevalence noted to be higher in the developed nations.6,7 Patient with paraesophageal hernia are usually older and the incidence increases with age. Patients with paraesophageal hernias can present with nonspecific symptoms such as gastroesophageal reflux symptoms or “heart burn.” Most of these symptoms usually managed conservatively with proton pump inhibitors. Other common symptoms include
Table 1. Key points.
FIGURE 2. Coronal CT image demonstrating stomach herinated through the diaphragm into the thorax. American Journal of Therapeutics (2015) 0(0)
Hiatal hernias can complicate and present with obstruction, strangulation, and volvulus. These are associated with high morbidity and mortality if not diagnosed early. A high degree of suspicion is required because in most cases the symptoms are nonspecific An urgent consultation with the surgical team would be the most appropriate next step in the management of a strangulated paraesophageal hernia There is no known medical therapy for the management of paraesophageal hernias. Symptomatic patients likely need surgical correction. Timing of this elective surgery is still debated www.americantherapeutics.com
Copyright Ó 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
It Is Not Always the Pulmonary Embolism
dysphagia, nausea and vomiting, coughing, and shortness of breath.8 Acute complications of paraesophageal hernia can be gastric volvulus with incarceration or strangulation. Gastric ischemia leading to perforation is the main cause of mortality when complications set in.9 Ozdemir reported 2 cases of strangulated paraesophageal hernia resulting in gastric gangrene.10 Sihvo et al11 reported 5 cases of strangulated paraesophageal hernia, which led to death in his population-based study between 1987 and 2001. There is no single mechanism that accounts for the development of paraesophageal hernia. Some of the proposed causes include shortened esophagus due to long-standing gastroesophageal reflux (GERD), imbalance between abdominal and intrathoracic pressures, age-related weakening of connective tissues, and imbalance of type 1 and type 2 collagen in the connective tissue of the hiatal orifice.9 Paraesophageal hernia is diagnosed using imaging or esophagogastroduodenoscopy. There is no medical treatment for a paraesophageal hernia, and symptomatic patients usually require surgical correction. The timing of this surgery still remains a debate. Most surgical corrections are now performed laparoscopically. Common things being common, a PE can cause chest pain and shortness of breath. However, anchoring of our diagnosis to this could have been detrimental to the patient. The importance of putting together all the pieces of a clinical presentation to avoid cognitive errors cannot be overstated.
www.americantherapeutics.com
3
REFERENCES 1. Pitts SR, Niska RW, Xu J, et al. National hospital ambulatory medical care survey: 2006 emergency department summary. Natl Health Stat Report. 2008;7:1–38. 2. Niska R, Bhuiya F, Xu J. National hospital ambulatory medical care survey: 2007 emergency department summary. Natl Health Stat Report. 2010;1–31. 3. Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophageal hernia repair. Arch Surg. 1997;132:586–589; discussion 590–591. 4. Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22:601–616. 5. Marano L, Schettino M, Porfidia R, et al. The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia. BMC Surg. 2014;14:1. 6. Ilves R. Hiatus hernia. the condition. Chest Surg Clin N Am. 1998;8:401–409. 7. Burkitt DP. Hiatus hernia: is it preventable? Am J Clin Nutr. 1981;34:428–431. 8. Richter JE. Typical and atypical presentations of gastroesophageal reflux disease: the role of esophageal testing in diagnosis and management. Gastroenterol Clin North Am. 1996;25:75–102. 9. Collet D, Luc G, Chiche L. Management of large paraesophageal hiatal hernias. J Visc Surg. 2013;150:395–402. 10. Ozdemir IA, Burke WA, Ikins PM. Paraesophageal hernia. A life-threatening disease. Ann Thorac Surg. 1973;16:547–554. 11. Sihvo EI, Salo JA, Rasanen JV, et al. Fatal complications of adult paraesophageal hernia: a population-based study. J Thorac Cardiovasc Surg. 2009;137:419–424.
American Journal of Therapeutics (2015) 0(0)
Copyright Ó 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
