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| IMAGE QUIZ |
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| Year : 2016 | Volume
: 4
| Issue : 2 | Page : 142-145 |
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Unusual cause of retrosternal chest pain
Yasser Aljehani
Department of Surgery, Thoracic Surgery Division, King Fahd Hospital of the University, University of Dammam, Dammam, Saudi Arabia
| Date of Web Publication | 9-Mar-2016 |
Correspondence Address:
Yasser Aljehani
Department of Surgery, Thoracic Surgery Division, King Fahd Hospital of the University, University of Dammam, Dammam
Saudi Arabia
 DOI: 10.4103/1658-631X.178372 PMID: 30787719 
How to cite this article:
Aljehani Y. Unusual cause of retrosternal chest pain. Saudi J Med Med Sci 2016;4:142-5 |
A 56-year-old female, known hypertensive on oral medications with a long history of gastroesophageal reflux disease, who underwent three laparotomies. The last two were for Nissen's fundoplication almost 8 years earlier to her presentation. She presented with progressive dyspnea mainly postprandial. Her physical examination was unremarkable as well as her laboratory investigations. The initial chest x-ray is shown in [Figure 1]. The barium swallow is illustrated in [Figure 2]. Computed tomography of the chest and upper abdomen is shown in [Figure 3] and [Figure 4] a-b.
| Questions | |  |
- What are the findings on initial chest radiograph?
- What are the findings on the barium swallow and CT?
- Is surgery indicated to treat such entity?
 View Answer
| Answers | | |
See the answers in page 145. | Answers | | |
- A large retrocardiac lucency with air-fluid level suggestive of hiatal hernia.
- Confirmed the diagnosis of hiatal hernia. Almost all the stomach is intrathoracic.
- Surgery is strongly advised since the risk of perforation is high.
ManagementThe patient underwent laparoscopic hiatal hernia repair. Conversion through thoracoabdominal approach was done due to short esophagus. She underwent Collis gastroplasty as well as cruroplasty. | Discussion | | |
Hiatal hernias are categorized into 4 types; type 1 (sliding) where the cardia slides upward, type 2 (paraesophageal) where the gastroesophageal junction is preserved while the anterior wall of the stomach moves into the mediastinum, type 3 (combined) where elements of both type 1 and 2 are the feature, and type 4 (giant paraesophageal) where more than half of the stomach or other abdominal organ is relocated into the mediastinum. [1] Clearly, this case is a type 4 hiatal hernia. For type 4, the risk of severe reflux, Cameron's ulcers due to linear gastric ulcerations, intrathoracic incarceration, strangulation, or perforation is high and contributes to high morbidity and mortality. [2] Postprandial dyspnea was reported in this case, but some have even reported heart failure due to the same pathophysiology. [3] Elective repair is strongly advocated to prevent stomach perforation and the subsequent catastrophe. [4]
| References | | |
| 1. | Dean C, Etienne D, Carpentier B, Gielecki J, Tubbs RS, Loukas M. Hiatal hernias. Surg Radiol Anat 2012;34:291-9.  |
| 2. | Camus M, Jensen DM, Ohning GV, Kovacs TO, Ghassemi KA, Jutabha R, et al. Severe upper gastrointestinal hemorrhage from linear gastric ulcers in large hiatal hernias: A large prospective case series of Cameron ulcers. Endoscopy 2013;45:397-400. |
| 3. | Shaikh I, Macklin P, Driscoll P, de Beaux A, Couper G, Paterson-Brown S. Surgical management of emergency and elective giant paraesophageal hiatus hernias. J Laparoendosc Adv Surg Tech A 2013;23:100-5. |
| 4. | Schieman C, Grondin SC. Paraesophageal hernia: Clinical presentation, evaluation, and management controversies. Thorac Surg Clin 2009;19:473-84. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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