Paraesophageal hernia with incarceration of the gastric antrum and duodenal bulb: a case report
© Takeuchi and Nomura; licensee BioMed Central Ltd. 2013
Received: 15 May 2013
Accepted: 8 November 2013
Published: 11 November 2013
In cases of esophageal hernia, incarceration of peritoneal organs other than the stomach is rare.
An 84-year-old female was admitted to our institution with a complaint of nausea and vomiting. Abdominal computed tomography revealed an esophageal hiatal hernia with incarceration of the gastric antrum and duodenal bulb. Gastrofluorography under gastroendoscopy confirmed prolapse of the antrum and duodenal bulb into the esophageal hernial sac. Although gastroendoscopy guided repositioning of the prolapsed organs was successful, reprolapse occurred immediately. Therefore, surgical treatment was indicated. The gastric antrum and duodenal bulb were associated with a paraesophageal hernia. Therefore, they were repositioned, and passage from the duodenal bulb to the descending portion of the duodenum was improved.
We report a rare case of paraesophageal hernia with incarceration of the gastric antrum and duodenal bulb.
KeywordsParaesophageal hernia Incarceration Surgery
In cases of esophageal hernia, incarceration of peritoneal organs other than the stomach is rare. We report a case of paraesophageal hernia with incarceration of the gastric antrum and duodenal bulb.
The incidence of esophageal hiatal hernia is increasing with the increase in the aging population, and approximately 60% of individuals aged > 50 years are affected with this condition . Esophageal hernia is defined as prolapse of all layers of the stomach, including the serosa, into the mediastinum. It is most common among patients with diaphragmatic hernia. Prolapse of peritoneal organs other than the stomach into the mediastinum is rare.
Hiatal hernias are classified into 4 types . In Type I, or sliding hiatal hernia, the gastroesophageal junction (GEJ) migrates cephalad through the hiatus into the thorax. In Type II, or paraesophageal hernia, the gastric fundus herniates through the hiatus into the thorax, but the GEJ remains in the abdomen. In Type III, which is a combination of types I and II, the GEJ and stomach herniate into the thorax. Type IV is a type III hiatal hernia with herniation of other organs into the thorax, such as the colon and spleen. Among these types of hernias, sliding hiatal hernia is the most common, accounting for 90%―95% cases of cases of esophageal hernia . Paraesophageal hernia is the second most common and accounts for 5% of cases . The etiologies of esophageal hiatal hernia include congenital opening of the esophageal hiatus, congenital deformity, acquired vulnerability of connective tissue because of obesity or aging, or increased abdominal pressure. In this case, the disorder was classified as paraesophageal hernia with involvement of the gastric antrum and duodenal bulb. Paraesophageal hernia presents most often in adults; therefore, acquired causes such as mechanical force and tissue degeneration are considered etiologic factors, although a congenital origin cannot be totally excluded.
The treatment for sliding esophageal hernia with mild gastroesophageal reflux is usually conservative. However, surgical treatment is recommended for sliding esophageal hernia refractory to conservative treatment, paraesophageal hernia liable to prolapse, or paraesophageal hernia with ulceration and/or stenosis. In cases of paraesophageal hernia, prolapse may suddenly occur, causing complications such as gastrointestinal necrosis by strangulation, gastric perforation, or massive hemorrhage. A high mortality rate is associated with paraesophageal hernia with complications; therefore, surgical treatment for paraesophageal hernia with or without complications is recommended.
Reports on the surgical treatment of esophageal hernia describe the repositioning of the hernial contents and closure of the hernial orifice. Two approaches are commonly used for the repair of esophageal hernias: the transthoracic approach and the transabdominal approach. The Allison  and Belsey― Mark IV technique  are transthoracic approaches. The techniques of Hill , Nissen , and Toupet  are transabdominal approaches. In this case, the transabdominal technique of Hill was used for inspection of the abdominal cavity, and, after repositioning the contents of the hernial sac, the superficial and deep layers of the diaphragmatic crura were easily closed using absorbable sutures. However, resection of the hernial sac could not be performed because of the transabdominal approach adopted in this case, but reportedly, it is not always necessary to perform the resection of the hernial sac .
Cases of esophageal hiatal hernia with incarceration of the gastric antrum and duodenal bulb
Type of hernia
Abdominal pain, abdominal distension
Abdominal distension, vomiting, weight loss
Anorexia, chest burning tarry, stool
We encountered a rare case of paraesophageal hernia with incarceration of the gastric antrum and duodenal bulb, which was corrected with surgical treatment because other treatment options failed to work. Therefore, even when complications are present, surgical treatment for paraesophageal hernia should be considered.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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