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
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.