Forrest Jonathan R, Chaudhuri Urmimala, Konney Evans, Triplett Drew J
Internal Medicine, Boonshoft School of Medicine, Wright State University, Dayton, USA.
Gastroenterology, Boonshoft School of Medicine, Wright State University, Dayton, USA.
Cureus. 2025 Aug 17;17(8):e90317. doi: 10.7759/cureus.90317. eCollection 2025 Aug.
Hiatal hernia (HH) is defined as the protrusion of abdominal contents through the esophageal hiatus of the diaphragm into the mediastinum. They are classified into categories I-IV. Type I, known as the sliding hernia, accounts for up to 90% of HH cases and are typically managed medically. Types II-IV combined account for less than 15% of HH cases. Types II-IV HH often require surgical repair, especially when symptomatic, due to the risk of complications such as gastric volvulus, obstruction, or strangulation. Furthermore, pancreatic herniation in a type IV HH has been shown to cause acute pancreatitis. We present the case of a 84-year-old female patient with gastroesophageal reflux disease (GERD) and type IV HH who presented with a three-day history of chest pain, abdominal pain, nausea, and vomiting. Urgent abdominopelvic computed tomography (CT) revealed a large HH containing the entire stomach, portions of the duodenum, colon, small bowel loops, and almost the entire pancreas - a combination that is rarely seen. The patient's symptoms resolved with ondansetron, fentanyl, and fluids, and she was discharged home from the ED with recommendations for gastroenterology follow-up. Although surgical management is considered definitive repair for type IV HH, this case highlights the possibility of non-operative medical management in chronic cases where the patient does not exhibit signs of ischemia, obstruction, volvulus, strangulation, or incarceration of the hernia. This case also highlights the importance of considering HH as a potential cause of chest pain, abdominal pain, nausea, and/or vomiting, especially in those with a history of GERD and already existing HH.
食管裂孔疝（HH）被定义为腹腔内容物通过膈肌的食管裂孔突入纵隔。它们被分为I - IV型。I型，即滑动疝，占HH病例的90%，通常采用药物治疗。II - IV型合起来占HH病例的不到15%。II - IV型HH通常需要手术修复，特别是出现症状时，因为存在诸如胃扭转、梗阻或绞窄等并发症的风险。此外，IV型HH中的胰腺疝已被证明可导致急性胰腺炎。我们报告一例84岁女性患者，患有胃食管反流病（GERD）和IV型HH，出现胸痛、腹痛、恶心和呕吐3天病史。紧急腹部盆腔计算机断层扫描（CT）显示一个巨大的HH，包含整个胃、部分十二指肠、结肠、小肠袢以及几乎整个胰腺——这种组合很少见。患者的症状通过昂丹司琼、芬太尼和补液得到缓解，她从急诊科出院，并被建议进行胃肠病学随访。尽管手术治疗被认为是IV型HH的确定性修复方法，但该病例凸显了在慢性病例中，当患者未表现出疝的缺血、梗阻、扭转、绞窄或嵌顿迹象时，非手术药物治疗的可能性。该病例还凸显了将HH视为胸痛、腹痛、恶心和/或呕吐潜在原因的重要性，特别是在有GERD病史且已存在HH的患者中。
