Giant hiatal hernia

Case contributed by Karol Dreżewski
Diagnosis certain

Presentation

Tachycardia-bradycardia syndrome. DDR-type pacemaker implantation.

Patient Data

Age: 90 years
Gender: Female

PA view X-ray

x-ray

Routine chest radiography after permanent pacemaker implantation in woman admitted to the hospital with symptoms of tachycardia-bradycardia syndrome.

The pacemaker leads are projected typically and there are no signs of pneumothorax.

A single, large air-fluid level overlapping the heart shadow is present. 

Follow-up CT scan

ct

Follow-up CT scan, ordered to rule out acute complications, showed stomach and proximal end of the duodenum herniated through widened esophageal hiatus into the intrathoracic, retrocardiac position.

The CT scan also confirms the correct placement of pacemaker leads. 

Sagittal view of the same study further establishes the diagnosis of giant hiatal hernia as an incidental finding.

Other findings include aortic calcifications and advanced spinal osteoarthritis with multilevel vacuum phenomena. Diffused enlargement and multiple nodules of the right thyroid gland lobe.

Case Discussion

Although sliding type constitutes more than 90% of hiatal hernias, cases of complete stomach herniation are uncommon.

The term "giant hiatal hernia" typically refers to a hernia that has at least 30% of the stomach in the thoracic cavity 1. The presence of a mass and/or single air-fluid level behind the heart shadow suggests the diagnosis.

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