Gastric perforation secondary to an incarcerated paraesophageal hernia

Abstract

Background: Paraesophageal hernias are usually asymptomatic; however, they can cause serious complications such as necrosis or incarceration-induced perforation. Necrosis usually occurs in the incarcerated portion of the hernia. Here, we report the case of a patient with gastric necrosis secondary to an incarcerated paraesophageal hernia in which the necrotic lesion was outside the hernia sac.

Case presentation: A 91-year-old woman presented with severe abdominal pain and vomiting. A physical examination showed hypotension and a diffusely tender and rigid abdomen. Computed tomography showed a paraesophageal hernia, massive ascites, and free air around the stomach. A laparotomy was performed to treat the upper gastrointestinal perforation. The stomach was incarcerated within the paraesophageal hernia sac. After reducing the stomach, we identified a large perforation on the posterior wall of the gastric fundus. Full-thickness necrosis involving part of the stomach necessitated total gastrectomy. She remained physiologically unstable and her condition deteriorated; she died 2 days postoperatively.

Conclusions: A hiatal hernia can be associated with an ischemic gastric perforation outside the hernia sac.

Keywords: Gastrectomy; Gastric perforation; Paraesophageal hernia.

Fig. 1

Preoperative computed tomography scan. Preoperative computed tomography scan (a, c, d) showing the gastric fundus and upper body incarcerated within the hiatal hernia (white arrow). The perforation (arrowhead) was located at the fundus outside the sac, which was locally ischemic and necrotic owing to complete cessation of blood supply (yellow arrow). All arteries, including the short gastric artery, were not clear on computed tomography, but arteries flowed into the sac at the hernia orifice (b, c, d) and disappeared

Fig. 2

Operative findings and schema. Most of the gastric body and half of the fundus were incarcerated. The antrum and part of the fundus were outside of the hernia sac. After stomach reduction, a 7-cm perforation was seen on the posterior wall of the gastric fundus

Fig. 3

Gross findings of specimen. The perforated area with ischemic necrosis was 7 × 4.5 cm in size at the posterior wall of the gastric fundus, which appeared very thin and dark red