78 y/o female with a history of CAD, cirrhosis, DM, and HTN presents with left arm pain, chest pain, and post-prandial dyspnea on exertion. Physical exam is unremarkable, except for an elevated blood pressure of 195/78. Troponin is negative and the EKG is unremarkable. Prior to obtaining a CT scan, bedside ultrasound is performed, revealing the following images.
Diagnosis: Large Hiatal Hernia
Bedside ultrasound demonstrated a fluid filled, occasionally peristalsing structure above the diaphragm, that had the appearance of the stomach. This structure was found to be abutting the left atrium when an echo was performed. A CT, shown below, confirmed the findings.
Hiatal hernias (HH) come in three varieties: Type I is the classic sliding hernia which accounts for 95% of all hiatal hernias. Type II is the paraesophageal hernia, Type III is a mixture of types I and II, and type IV is when there is herniation of other abdominal contents into the posterior mediastinum.1
Hiatal hernias can cause the gastroesophageal junction to become incompetent, increasing the incidence of GERD. 1
Ultrasound (US) has been shown to be a promising adjunct study in the evaluation of a patient with a hiatal hernia. One study found ultrasound to have a PPV of 82.7% and a NPV of 97% in the detection of HH. 2
Ultrasound has also been shown to have a high correlation with CT diagnosis of HH. One study found an agreement of 0.995 between the two imaging modalities.3
HH should be on the differential in a patient with chest pain,4 and in fact syncope due to compression of the LA from a large HH has been described, as we saw in our patient.5
Hyun JJ, Bak YT. Clinical significance of hiatal hernia. Gut Liver. 2011;5:(3)267-77. [pubmed]
Barone M, Di Lernia P, Carbonara M, et al. Sliding gastric hiatal hernia diagnosis by transabdominal ultrasonography: an easy, reliable and non-invasive procedure. Scand J Gastroenterol. 2006;41:(7)851-5. [pubmed]
Cakmakci E, Celebi I, Tahtabasi M, et al. Accuracy of ultrasonography in the diagnosis of sliding hiatal hernias. Acad Radiol. 2013;20:(4)453-6. [pubmed]
Koskinas KC, Oikonomou K, Karapatsoudi E, Makridis P. Echocardiographic manifestation of hiatus hernia simulating a left atrial mass: case report. Cardiovasc Ultrasound. 2008;6:46. [pubmed]
Oishi Y, Ishimoto T, Nagase N, et al. Syncope upon swallowing caused by an esophageal hiatal hernia compressing the left atrium: a case report. Echocardiography. 2004;21:(1)61-4. [pubmed]