PARAOESOPHAGEAL HIATUS HERNIA

PARAOESOPHAGEAL HIATUS HERNIA

RAJESH C KAMBLE*, RAVI V RANANAVRE**, DEVDAS S SHETTY***, ALPANA N JOSHI***, SANJAY N OAK+, SONALI TANK++, SUSHMA MALIK+++, SUREKHA M JOSHI+
*2nd Year Resident; **Professor and Head; ***Associate Professor; Department of Radiological, BYL Nair Hospital, AL Nair Road, Mumbai 400 008. +Professor and Head; ++Lecturer; +++Associate Professor, Department of Paediatrics, BYL Nair Hospital, AL Nair Road, Mumbai 400 008.

We report an interesting case of a paraoesophageal hernia in a six year old child.

INTRODUCTION

Paraoesophageal hiatus hernia is a relatively uncommon entity in children characterized by axial cephalad migration of stomach into the thorax through an abnormally wide oesophageal hiatus with the gastrooesophageal junction in its normal intraabdominal position.
CASE REPORT

A six-year-old child presented with intermittent low-grade fever since four months. The father gave history of melaena for last three years. The patient was treated ten months ago for pulmonary consolidation and the chest radiograph showed a well-defined radio-opacity in the right paracardiac region not obscuring the right heart border (Fig. 1).
The present chest radiograph revealed a large thin walled cavity in the right paracardiac region with an air fluid level suggestive of lung abscess/infected congenital lung cyst as a possible diagnosis and the patient was started on intravenous antibiotics (Fig. 2). Laboratory investigations revealed a microcytic hypochromic anaemia and occult blood in stools.

Subsequent radiographs revealed a variable pattern in the radio-opacity as well as contained the fluid level within the cavity.

Despite prolonged antibiotics there was no therapeutic response. Finally on review of all the radiographs brought to us after a period of one month, the features like persistent fluctuations of the fluid level in the cavity and absence of the fundic gas bubble were noted and hence a probable diagnosis of diaphragmatic hernia was considered. Being unable to accept oral feeds, a Ryle’s tube was passed which was found to lie within the cavity in the right paracardiac region (Fig. 3).

Subsequently barium examination was performed which revealed a barium filled stomach lying in the right hemithorax and the fundus, greater and lesser curvature were seen to lie above the diaphragm and the gastrooesophageal junction was in its normal anatomical position (Fig. 4). On basis of all the findings, a diagnosis of rolling hernia was made.

At surgery our radiological findings were confirmed and reduction of hernia with gastropexy and hernia repair was performed.

Fig. 1: Chest radiograph shows a well-defined radio-opacity in the right paracardiac region.

Fig. 2: Repeat chest radiograph (after 2 weeks) shows a large thin walled cavity in the right paracardiac region with an air fluid level.

Fig. 3: Chest radiograph shows a Ryle's tube lying within the cavity in the right paracardiac region.

Fig. 4: Barium examination shows a barium filled stomach lying in the right hemithorax. the fundus, greater and lesser curvatures were above the diaphragm and the gastroesophageal junction in its normal anatomical position.

DISCUSSION

Paraoesophageal hiatus hernia is an uncommon entity in childhood accounting for only 5% of all diaphragmatic hernias[1] with a male to female ratio of 1:4.

The condition is more common in adults than children but congenital paraoesophageal hernias in infancy has been reported in literature.[1]

Broadly two different aetiologies appear to exist, one being the acquired variety seen commonly in the elderly and the other is a congenital variety as seen in our case.[1] In the latter, persistence of the pneumatic enteric recess after the development of the pleuroperitoneal membrane and an aberration in the embryonal development of the lumbar component of the diaphragm, which originates from the mesodermal cells around the aorta have been proposed as possible aetiologies.

Most of the cases are completely asymptomatic with vague signs like microcytic hypochromic anaemia (55%),[2,3] occult blood in stools and failure to thrive (31%).

On erect chest radiograph a cystic radio-opacity extending to the right or left of the cardiac silhouette is seen with an absent fundic gas bubble.[4]

Barium examination will settle the diagnosis with the classic "sickle and wheel" configuration as seen in our case.

Endoscopy plays a role prior to surgery, which reveals retroversion of the scope and a separate orifice adjacent to the gastro-oesophageal junction into which the gastric folds ascend.[5]

Complications like persistent upper gastrointestinal haemorrhage (55%),[2,3] gastric volvulus with strangulation,[6,7] incarceration, obstruction (30%),[7] perforation and sepsis[1] occur with a hospital mortality rate of 50%.

Apart from open surgical repair, laparoscopic repair has an emerging role to play in the treatment of such cases.[7]

In conclusion, this case highlights the fact that a clinicoradiological correlation is an absolute necessity for arriving at an accurate diagnosis and achieving speedy recovery.

ACKNOWLEDGEMENTS

The authors wish to thank the Dean, Topiwala National Medical College and BYL Nair Charitable Hospital for permitting this publication.

REFERENCES

1. Jaward AJ, al-Samarrai AI, al-Mofada S, al-Howasi M, Hawass NE, al-Beiruti Z. Congenital Paraoesophageal hiatal hernia in infancy. Paediatric Surgery International 1998; 13 (2-3) : 91-4.

2.Edmunda V. Hiatus hernia, a clinical study of 200 cases. Q J Med 1957; 26 : 445.

3.Windsor CWO, Collis JL. Anemia and hiatus hernia: Experience in 450 patients. Thorax 1967; 22 : 73.

4.Blatt ES, et al. Roentgen findings in obstructed diaphragmatic hernia. Radiology 1962; 79 : 648.

5.De Meester TR, Bonavina L. Paraoesophageal hiatal hernia. In Nyhus LM, Condon RE (eds), Hernia, 3rd ed. Philadelphia. JB Lippincott. 1989; 689.

6.Foscolo PP, Santaro P. A complicated paraoesophageal diaphragmatic hernia. A clinical case report. Minerva Chirurgica 1998; 53 (6) : 523-6.

7.Rodefeld MD, Soper NJ. Paraoesophageal hiatal hernia with volvulus and incarceration. Laparoscopic repair of a rare defect. J Gastrointestinal Surgery 1998; 2 (2) : 193-7.

To section TOC


Fig. 1: Chest radiograph shows a well-defined radio-opacity in the right paracardiac region.	Fig. 2: Repeat chest radiograph (after 2 weeks) shows a large thin walled cavity in the right paracardiac region with an air fluid level.

Fig. 3: Chest radiograph shows a Ryle's tube lying within the cavity in the right paracardiac region.	Fig. 4: Barium examination shows a barium filled stomach lying in the right hemithorax. the fundus, greater and lesser curvatures were above the diaphragm and the gastroesophageal junction in its normal anatomical position.