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Giant paraesophageal hernia - in a toddler

Case contributed by Chi Lap Nicholas Tsang
Diagnosis certain

Presentation

A 19-month old male was brought into the emergency department by parents after general practitioner review for failure to thrive, lethargy, and anorexia and a finding of profound iron deficiency anemia. Hemoglobin was 50g/L and ferritin was 2 ug/L.

Patient Data

Age: 19 months
Gender: Male

AP and lateral chest X Rays demonstrating a posterior mediastinal mass with air-fluid levels suggestive of gastrointestinal origin.

CT chest, abdomen, and pelvis demonstrating a giant (>30% stomach herniated) congenital paraesophageal hernia containing the stomach and transverse colon (Type IV).

Day 1 post-operative chest X-ray demonstrating post-operative esophageal and stomach changes with no further herniation of gastrointestinal contents into the thorax.

Case Discussion

The cardiac silhouette was preserved with obtuse lung margins suggesting a mediastinal mass over cardiomegaly or a lung parenchymal etiology.  Benign causes in this age group include thymoma, hernia, abscess, or many others. Malignant causes could include lymphoma, or germ cell tumors among many others.  A lateral view aided in the differential due to the presence of an air-fluid level which favored a gastrointestinal etiology.  

The patient subsequently received a CT interrogation confirming the presence of stomach and transverse colon contents herniating through a widened esophageal hiatus centered at T10.  The patient was referred to a tertiary pediatric surgery facility and underwent a laparoscopic hiatus hernia repair with mesh, fundoplication, and gastrostomy for decompression and enteral access.  The patient was discharged 6 days postoperatively into the community.  

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