Intrathoracic gastric perforation: a late complication of an unknown postpartum recurrent hiatal hernia

Abstract

Diaphragmatic hernias occurring during pregnancy are an uncommon event. In very rare occasions, the clinical situation can suddenly worsen due to obstruction, torsion or infarction of the herniated viscera. Here, we describe a challenging case of a post-partum diaphragmatic hiatus hernia complicated by intrathoracic gastric perforation. A 23-year old woman was admitted at our hospital with a syndrome characterized by epigastralgy, dyspnoea and fever. She had previously undergone a laparoscopic antireflux surgery for hiatus hernia (6 years before) and a recent (4 months) unremarkable vaginal delivery. Due to the persistence of a pelvic pain after the delivery, she had been taking pain-killers as a self-administered medication. A CT scan showed a massive left pleural effusion and a complete herniation of the stomach into the left hemithorax. After placing a chest drainage and removing up to 3000 ml of brownish purulent fluid, a repeat CT scan (with water soluble contrast swallow) showed a leak at the level of the stomach. At surgery, we observed a complete intrathoracic herniation through a large diaphragmatic hiatal defect and a small well-defined gastric ulcer. A primary repair of both the stomach and the diaphragm was performed. We take the opportunity presented by this report to briefly discuss the patho-physiological mechanisms underlying this unusual complication.

Figure 1:

First CT scan performed at admission in Emergency Department showed a massive left pleural effusion associated with severe contralateral mediastinal shift (A) and a complete intrathoracic gastric herniation (B). A second CT scan performed after chest tube placement and during water soluble contrast examination demonstrated the leak at the level of the stomach (C) and documented only a partial re-expansion of the pulmonary parenchyma (D).

Figure 2:

Surgical findings during emergency thoracotomy: complete intrathoracic gastric herniation through a large diaphragmatic hiatal defect without macroscopic signs of visceral strangulation (A); a small well-defined gastric ulcer (about 1 cm in size) was found at the level of lesser curvature (B).