Acutely Obstructed Hiatal Hernia

J. MuRRAY BEARDSLEY, M.D., WILLIAM R. THOMPSON, M.D.

From the Surgical Service, Rhode Island Hospital, Providence, Rhode Island

DURING the past decade many worth-while contributions have been made to thesubject of esophageal hiatal hernia. Im-proved radiologic technics for detection ofthe hernia, a more intelligent selection ofpatients for operation, and simplificationand refinements of the repair have in-creased the range of operability to includea host of sufferers to whom operation hadformerly been denied. However, one phaseof the problem which has received too littleattention is the management of the acutelyobstructed hiatal hernia in its variousforms.The repair of a hiatal hernia is under-

taken either to relieve the patient of trou-blesome symptoms, or to deal with its moreserious complications, and since acute ob-struction is one of the less frequent it isnot surprising that there is a general lackof understanding of this most serious con-dition. There would also appear to be someconfusion of the terminology that has beenused to describe hiatal hernia associatedwith obstruction. We are, therefore, includ-ing our own classification as it relates toincarceration and obstruction in the regionof the esophageal hiatus.

Case reports of 15 patients, 13 dealingwith acute obstruction and two withchronic incarceration without obstruction,in an operative experience of 537 cases ofhiatal hernia at Rhode Island Hospital, areincluded in the present communication.

Case ReportsCase 1. I. K., a 71-year-old woman, was ad-

mitted at 11:40 p.m. on November 1, 1959. Fol-

lowing a heavy meal on the evening of admis-sion, she had severe upper abdominal pain andretching. She was known to have heart disease andhad been taking digitalis and for over two years,had required cortisone daily for severe asthma.

Examination revealed an acutely ill, elderlywoman complaining of severe upper abdominaldistress. She retched constantly, but was unableto vomit. A nasogastric tube was passed, but itdid not appear to enter the stomach and no drain-age was obtained. There was a firm, rounded,slightly tender mass palpable in the epigastrium.An emergency gastro-intestinal x-ray series showedthe distal half of the stomach above the diaphragmwith the greater curvature as its upper borderand the proximal half of the stomach below thediaphragm with the pylorus overlying the cardio-esophageal junction (Fig. 1).

After adequate hydration, an emergency op-eration was performed through a right subcostalincision. A portion of tremendously dilated stom-ach presented in the left upper quadrant. Theantral portion of the stomach had migrated intothe chest through a large defect in the region ofthe esophageal hiatus where a volvulus had oc-curred. After inserting a trocar, and aspirating theabdominal segment of 2,000 cc. of fluid and aconsiderable amount of gas, fluid drained fromthe thoracic into the abdominal segment afterwhich the thoracic portion literally fell out ofthe chest. There was no compromise of the bloodsupply to the stomach. A large, thickened, edem-atous sac was excised and the defect firmly closedwith 1-0 silk, and a gastrostomy performed usinga No. 22 catheter.The patient's convalescence was uneventful and

she had no further difficulty.Case 2. N. J., a 75-year-old woman, was ad-

mitted on January 16, 1959, with a history ofepigastric and left upper quadrant pain and in-tractable vomiting of 48 hours' duration. Thevomitus was tea-colored, but there was no historyof frank hematemesis, or melena. There had beena 40-pound weight loss in the preceding six-month period. Five years before, she had beenadmitted to another hospital with similar, but lesssevere symptoms and x-ray study revealed a large

49

* Submitted for publication January 7, 1963.

BEARDSLEY AND THOMPSON Annals of SurgeryJanuary 1964

FIG. 1 (Case 1). A combination of the organo-axial and the mesentero-axial types of volvu-lus. This also is an example of the partial type of volvulus with the proximal portion belowthe diaphragm and the distal portion above.

hiatal hernia. Surgical treatment at that time was

believed to be inadvisable.Examination of the chest revealed hyperactive

bowel sounds in the left hemithorax. There was

hyper-resonance anteriorly on the left side up to

the fourth rib which was interpreted as dilatedstomach. Abdominal examination was essentiallynegative. Her temperature was 37.7° C., respira-tions 18, and blood pressure 110/86. A gastro-intestinal x-ray series revealed twisting of thestomach in the region of the proximal portion ofthe body as it was directed upward through thehiatus suggesting the presence of a volvulus. Thex-ray impression was "upside-down stomach withevidence of a volvulus, the point of twisting beinglocated at the junction of the cardia and media."

The patient obtained complete relief of symp-

toms after evacuation of a large amount of gastriccontents by means of a Levin tube. At operationon January 22, the distal two-thirds of the stomachwas found to be in the chest. The duodenum,which was tremendously elongated, extended up-

ward to within one inch of the hiatus. The stom-

ach was drawn down into the abdominal cavitywithout difficulty after which the hiatal openingwas seen to be very large, easily admitting theentire fist. The defect was repaired, and a gas-

trostomy performed. The patient had a benignconvalescence except for a partial atelectasis ofthe left lower lobe and she was discharged fromthe hospital on February 1.

Case 3. J. B., a 79-year-old woman, was ad-mitted on September 12, 1955, with a chief com-

plaint of moderately severe upper abdominal painof five days' duration. The pain radiated to theback and chest. She had not vomited, and no

history of previous gastro-intestinal disturbancewas given.

Examination revealed an elderly woman withmoderate upper abdominal distress. Loud gur-

gling bowel sounds were heard on auscultation ofthe lower chest bilaterally. There was some dis-tention and tenderness in the upper abdomen withhigh pitched bowel sounds. Her temperature was

37.40 C., pulse 84, respirations 20, blood pressure

110/70, hemoglobin 13.9 Gm., and white bloodcell count 11,600 (84%o polys).

X-ray films of the chest and abdomen showedthe stomach and a dilated loop of bowel abovethe diaphragm, and a distended loop of bowelin the right abdomen. Since the insertion of a

Levin tube gave no relief, operation was performedon the day of admission after adequate intra-venous therapy.

On opening the peritoneal cavity, the ascend-ing and proximal transverse colon were found to

be greatly dilated. The right colon was decom-pressed by placing a No. 28 catheter in the cecum

through which a large quantity of gas and fluidwas evacuated. There was an obstruction due to

incarceration of both the transverse colon andthe entire stomach in the thoracic cavity through

50

ACUTELY OBSTRUCTED HIATAL HERNIA

|. .:..:.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~'. ..... :..

Fi(;. 2 (Case 4). The only case in the present series of acute obstruction within a sli(linig hiatalhernia. X-ray demonstrates torsion at the mid portion of the stomach.

the esophageal hiatus. Using gentle traction, thestomach and transverse colon were delivered intothe abdominal cavity. The esophageal hiatus was

found to be tremendously enlarged and measured16 X 12 cm. It extended anteriorly to the sternumand posteriorly to the vertebral column. How-ever, despite its large size, the margins were

relaxed and it was easily closed to a normal size.The patient withstood the procedure well and

left the operating room in good condition. She ob-tained complete relief from her preoperative symp-

toms and was doing well until the evening of thesecond postoperative day when she developed a

left hemiplegia and became unconscious. She never

regained consciousness, and expired on September22.

Case 4. E. L., a 75-year-old woman, was ad-mitted on July 24, 1961, with a 48-hour historyof abdominal pain and persistent vomiting. Thepain was crampy in character and was generalizedthroughout the abdomen.

Ten years prior to admission, a hiatal herniahad been demonstrated by x-ray. Through theyears this had been treated with diet, antacids,demerol, and by sleeping with her head elevated.An abdominal hysterectomy had been performed35 years before. She was a moderately severe dia-betic with a history of heart failure, and shewas taking digitalis.

Examination revealed a thin, dehydrated

woman complaining mildly of abdominal pain.There was moderate abdominal distention withhyperactive bowel sounds. Her temperature was

36.60 C., pulse 90, respirations 24, blood pressure

116/64, hemoglobin 13.5 Gm., and the white bloodcell count was 25,700 (84% polys).

An emergency gastro-intestinal x-ray series re-

vealed a large sliding hiatal hernia with the entirestomach in the chest with complete twisting atthe junction of the fundus and media. The esoph-agus was angulated and displaced to the left (Fig.2). Barium entered the fundus, but did not pass

into the remaining portion of the stomach. Anarrowing was visualized between the fundus andmedia with torsion of the folds in this region.Numerous distended loops of small bowel were

present in the lower two-thirds of the abdomenconsistent with small bowel obstruction.

After routine preparation, operation was per-

formed on July 25. The preoperative diagnosiswas small bowel obstruction due to adhesions andincarceration of the hiatal hemia from increasedabdominal distention. Therefore, a long para-

median, rather than the usual right subcostal,incision was used. The terminal ileum, whichwas collapsed, was followed to the pouch ofDouglas where adhesive bands were divided andan obstruction relieved. The pylorus was visiblebelow the diaphragm, but the remainder of thestomach was in the chest. By making gentle trac-tion on the pylorus, a tremendously dilated stom-

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52 BEARDSLEY AND THOMPSON

ach was delivered out of the chest. Before pro-ceeding with repair of the defect, a gastrostomywas carried out and a large quantity of air, barium,and gastric contents was evacuated. A large, thick,edematous sac was excised and the hernia re-paired. She had an uneventful recovery and wasdischarged on August 16, but re-admitted onAugust 18 because of persistent vomiting andevidence of heart failure. Gastro-intestinal x-rayseries revealed obstruction of the gastric outlet.This was treated conservatively and the cardiacdecompensation corrected after which deep phle-bitis in the left leg was noted. Since the pyloricobstruction persisted, reoperation was carried outon August 25. On opening the peritoneal cavity,the greatly elongated duodenum was found tohave become angulated and adherent to theundersurface of the liver. A gastroenterostomy andgastrostomy were performed. Both femoral veinswere explored and large clots removed from theleft common femoral vein. She withstood the pro-cedures well and at the time of discharge, onSeptember 19, was eating normally and had nofurther evidence of obstruction. A gastro-intestinalseries showed a normally-functioning gastroen-terostomy.

The patient was last seen on December 4,1962, at which time her general condition wasexcellent. She was free of all complaints and lead-ing a normal and active life.

Case 5. E. A., a 72-year-old woman, was ad-mitted on February 7, 1955, with symptoms andfindings consistent with a deep thrombophlebitisof the right lower leg. At the time of admissionshe gave a three-year history of intermittent se-vere episodes of epigastric distress, retrosternalpain, and nausea and vomiting which were ag-gravated by lying down. These attacks usuallylasted three to four days during which time shewas able to retain very little of her oral intake.The most recent attack occurred two weeks priorto the present admission. A gastro-intestinal x-rayseries obtained eight months previously demon-strated a large hiatal hernia. She had lost 40pounds during the past year.

The patient did not appear acutely ill, butwas malnourished and seemed older than herstated age. Calf tenderness and edema were pres-ent in the right lower extremity. Numerous extra-systoles were detected and there was minimalcardiac enlargement to the left. Epigastric tender-ness was elicited by deep palpation.

Chest x-ray films demonstrated a large hiatalhernia. An electrocardiogram revealed an irregu-lar rhythm due to occasional ventricular and au-ricular extrasystoles.

Annals of SurgeryJanuary 1964

The patient was treated with bed rest andanticoagulants. The thrombophlebitis subsided,but she continued to vomit intermittently. In spiteof a strict medical regimen, the vomiting per-sisted, and on the 22nd hospital day repair of ahuge incarcerated paraesophageal hernia was car-ried out. She tolerated the operative procedurewell and her convalescence was uneventful untilthe seventh postoperative day when she suddenlywent into shock. An electrocardiogram was con-sistent with the diagnosis of pulmonary embolus.Her condition deteriorated rapidly and she expiredon her eighth postoperative day.

Case 6. J. T., a 67-year-old woman, was ad-mitted on January 15, 1957, with the chief com-plaint of intermittent vomiting of one-year dura-tion. During the month prior to admission shehad experienced daily vomiting associated withsubsternal discomfort of a rather severe nature.Nine years before this admission the patient hadhad a severe episode of upper abdominal painradiating to the anterior mid-chest. Subsequentwork up at another hospital at that time demon-strated a hiatal hernia. She had been a knownhypertensive for the past six years and had hadoccasional syncopal episodes.

At the time of admission the patient was notacutely ill. Her blood pressure was 210/112, andthe heart was enlarged slightly to the left. Ex-amination of the lungs and abdomen was nega-tive. A chest x-ray film demonstrated a very largeesophageal hiatal hernia extending beyond thecardiac borders in the posteroanterior view pro-ducing a shadow 18 cm. in diameter. The elec-trocardiogram demonstrated some degree of coro-nary insufficiency and left ventricular strain.

At operation, all of the stomach, which wasfour to five times its normal size, and most ofthe transverse colon were found to be containedwithin a hernial sac in the posterior mediastinum.The hernia was easily reduced and a routine re-pair carried out and a gastrostomy performed.

The patient tolerated the procedure well, buton the second postoperative day developed atransitory shock-like state and a left hemiplegia.She was transferred to the medical service on thetenth postoperative day for further care, but ex-pired soon afterward following a second similarepisode.

Case 7. J. W., a 76-year-old woman, was ad-mitted on November 24, 1960, with a history ofsudden and severe pressure-like pain in the sub-sternal and epigastric regions of six hours' dura-tion. Two hours after the onset of pain, she hadvomited once. This was followed by persistentretching. She stated that the pain was worse when

ACUTELY OBSTRUCTED HIATAL HERNIA 53

FIG. 3 (Case 7). The most common type representing an upside-down stomach and a completevolvulus. The stomach has rotated through its long axis (organo-axial).

lying down and on deep breathing and radiatedto her back and shoulders. It was somewhat re-

lieved by sitting up and leaning forward. She hadhad a similar attack one year before which lastedfor a few hours. A gastro-intestinal x-ray seriesdone four years prior to admission revealed an

esophageal hiatal hernia.The patient was an elderly, well developed,

and well nourished woman. She was sitting up inbed complaining of constant lower substemal painand appeared to have some difficulty breathing.Her temperature was 36.1° C., pulse 88, respira-tions 32, blood pressure 180/108. Breath soundswere diminished at the base of the left chest. Theabdomen was negative except for moderate tender-ness in the epigastrium. Her white blood cellcount was 10,500 (80% polys) and hemoglobin10.4 Gm.

On the day following admission, she was seen

in consultation and an emergency gastro-intestinalx-ray series ordered. X-ray films of the chest dis-closed an air fluid level behind the heart consistentwith a large hiatal hernia. X-ray of a bariumswallow demonstrated "an unusually large para-

esophageal hiatal hernia with the entire fundusand media of the stomach situated in the thoraciccavity in an inverted position." It was possibleto pass a Levin tube into the stomach with therecovery of a large amount of gastric contentswith some relief of symptoms.At operation on November 26, the pylorus was

visible beneath the diaphragm, but the remainderof the stomach was in the chest. Using gentle trac-tion the stomach was delivered into the peritonealcavity, a large edematous sac excised, and a rou-

tine repair of the defect carried out.The patient's convalescence was uneventful

and she was discharged on December 7 and hasremained well.

Case 8. E. C., an 83-year-old woman, was ad-mitted on June 15, 1959, after a 48-hour historyof nausea and vomiting. These complaints startedsuddenly, awakening her from sleep, and subse-quently she vomited each time she ingested solidfood or liquid. During the two-year period priorto admission, she had experienced several similarattacks of prolonged vomiting. She also gave a

history of epigastric distress following meals ofmany years' duration that was somewhat relievedby standing.

Physical examination revealed a well devel-oped and well nourished, moderately dehydrated,elderly woman who did not appear acutely ill.Her temperature was 37.20 C., respirations 20,pulse 80, and blood pressure 188/98. A few finerales were present at both lung bases and theheart was enlarged slightly to the left. A GradeIII harsh systolic murmur was present over theaortic area and A2 was barely audible. The ab-dominal examination was negative.

Shortly after admission a Levin tube was in-

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54 BEARDSLEY AND THOMPSON

troduced into the stomach and 700 cc. of coffeeground material, positive for occult blood, wasobtained. The tube was left in place on inter-mittent suction. The patient's hemoglobin was 8.3Gm. and her white blood cell count moderatelyelevated. Mild azotemia and hypokalemia werepresent. A gastro-intestinal x-ray series performedshortly after admission revealed a large para-esophageal hernia with the entire stomach withinthe chest.

At operation on the second hospital day thepreoperative impression of incarceration was sub-stantiated and the stomach was returned to theabdominal cavity, the large defect repaired, andgastrostomy performed.

The patient tolerated the procedure well andhad a benign course until the ninth postoperativeday when she became febrile and developed arapid irregular pulse. Her course was downhillthereafter, and she died on the 14th postoperativeday. At postmortem examination, extensive bi-lateral pulmonary emboli were found, althoughthe source could not be determined.

Case 9. M. WV., a 71-year-old woman, was ad-mitted on November 14, 1960. She had two pre-vious admissions, the first on December 11, 1956,with severe and persistent vomiting and upperabdominal pain. X-ray examination revealed gall-stones and an incarcerated hiatal hernia whichreduced itself during the course of the gastro-intestinal study. She was discharged on December16, but re-admitted on November 18, 1958, withthe complaint of nausea and vomiting for fourdays. Since discharge she had mild symptomsrelating to her stomach, but no acute attacks.She appeared weak and she was severely de-hydrated. BUN level was 69 mg.%. Stools werenegative for occult blood. A Levin tube waspassed with the evacuation of a large quantity ofgastric contents with immediate relief of symp-toms. She was discharged on November 23.

Three days prior to the present admission, sheagain had recurrence of persistent and severevomiting. She appeared critically ill and wassemi-comatose. Her pulse was weak and her bloodpressure unobtainable, but she showed markedimprovement after intravenous therapy and inser-tion of a nasogastric tube which resulted in escapeof a considerable amount of gastric contents. Herhemoglobin was 12.9 Gm., white blood cell count15,200 (83%o polys) and blood glucose 169, urea47, creatinine 2.1 mg.%o. On November 16, herhemoglobin dropped to 8.8 Gm. and she waspassing tarry stools. A gastro-intestinal x-ray seriesagain revealed the stomach to occupy an upside-down position within the chest with narrowingand twisting of the mucosal folds of the esophago-

Annals of SurgeryJanuary 1964

gastric junction and of the gastric outlet. Thepatient was seen for the first time in surgicalconsultation on November 20. On November 22,she suddenly passed 800 cc. of bright red bloodthrough the gastric tube and became shock-likeand at 8:30 p.m. she had a convulsion and fainted.Her condition improved following multiple bloodtransfusions but bleeding continued and an emer-gency operation was performed. On opening theperitoneal cavity, the upper abdomen was filledwith a tremendously dilated gastric fundus withobstruction of the outlet. The antrum, transversecolon, and great omentum had herniated into thechest through the hiatus. After reducing thehernia, the stomach was widely opened and foundfilled with fresh blood and clots which were evac-uated. The stomach was thoroughly flushed outand a search made for bleeding points, but nonewere found. The stomach was closed, a gastros-tomy performed, and the hemia repaired. Ninehours postoperative, the patient had another mas-sive hemorrhage and went into shock. She wasagain taken to the operating room and the stom-ach opened and found to be filled with freshblood. This was evacuated and a high subtotalgastrectomy carried out. Multiple bleeding pointsfrom the mucosa of the remaining small cuff ofstomach were sutured before performing the gas-trojejunostomy. She was returned to the ward inpoor condition. Frequent tracheobronchial aspira-tions were required and on the following morninga tracheotomy was performed with rather dramaticimprovement in her general appearance. No fur-ther bleeding occurred and the remainder of herconvalescence was unremarkable except for woundinfection which delayed her discharge from thehospital.

The patient has remained well and has hadno further gastro-intestinal symptoms.

Case 10. E. G., a 59-year-old woman, was ad-mitted on November 9, 1957, with severe dysp-nea. The respiratory distress was so acute that thepatient was unable to give a history, but it wasdetermined from previous records that she hadsporadic digitalis therapy in the past because ofa history of heart disease. Four years previouslythe patient had been admitted to this hospitalbecause of dyspnea and intermittent anterior chestpain. A profound iron deficiency anemia was de-tected and a gastro-intestinal x-ray series demon-strated a large, para-esophageal hernia involvingthe entire fundus and a portion of the media.Electrocardiogram at that time was normal.

At this admission the patient was markedlyorthopneic and cyanotic. Her temperature was

37.70 C., pulse 160, respirations 40, and bloodpressure 100/60. Coarse rales and rhonchi were

ACUTELY OBSTRUCTED HIATAL HERNIA

present throughout both lung fields. The ab-dominal examination was negative. No peripheraledema was present. A technically unsatisfactoryportable chest x-ray film was interpreted as show-ing bilateral pleural effusion.

A provisional diagnosis of acute pulmonaryedema secondary to heart failure was made andthe patient was treated intensively with rotatingtourniquets, aminophylline, morphine, phlebotomy,and rapid digitalization despite which her condi-tion deteriorated rapidly, and she expired 41Ahours after admission.

At autopsy a severe pneumonic process in theright lung was apparent. In addition, a large ob-structed, incarcerated para-esophageal hernia was

found severely compressing the left lung and dis-placing the heart anteriorly and to the right.Within the sac was 75 per cent of the stomachcontaining 1,000 cc. of fluid, almost the entiregastrocolic omentum, and 22 cm. of transversecolon. The heart itself showed only mild coronaryarteriosclerosis, and there was a notable lack ofsigns of chronic cardiac disease, or failure.

Case 11. L. H., a 73-year-old woman, was ad-mitted on May 28, 1957, because of nausea, vom-

iting, and epigastric pain occurring intermittentlyover the previous ten-year period. As a rule thepain subsided shortly after vomiting. The episodesgradually became more frequent, the most recentattack, which lasted for two weeks, occurringfour weeks prior to the present admission. Agastro-intestinal x-ray series performed soon afterthis demonstrated a large incarcerated and ob-structed parahiatal hernia which also containedtransverse colon. Since the attack, liquids were

tolerated only in small amounts.Physical examination on admission was un-

revealing. The routine laboratory studies were allnormal. Operation was promptly carried out inthe routine fashion. The hiatal defect was fiveinches in diameter, but was closed easily afterreturning the stomach to the abdominal cavity.After a smooth postoperative course, the patientwas discharged and remained asymptomatic untilthe time of her death from an unassociated condi-tion almost two years later.

Case 12. M. W., a 57-year-old woman, was ad-mitted on October 1, 1962, with upper abdominaland low anterior chest pain associated with inter-mittent vomiting of one week duration. Threed-ays prior to admission the pain became intenseand all oral intake was vomited soon after inges-tion. In the patient's own words, "it felt as if a

large balloon was continuously expanding" in thelower chest and upper abdomen. Two years pre-viously a hiatal hernia had been detected by

FIG. 4 (Case 12). This x-ray is of interestsince it demonstrates the Levin tube lying withinthe proximal dilated segment allowing for decom-pression with relief of obstructive symptoms. An-other example of partial organo-axial volvulus.

chest x-ray during work up for hypertension, butexcept for occasional heartburn during the pastyear there were no gastro-intestinal complaints.

On admission the patient was in moderate dis-tress from abdominal pain and nausea. Her bloodpressure was 180/110, pulse 104, temperature37.60 C. White blood cell count was 17,200 witha shift to the left in the differential count. BUNlevel was 73 mg.%. Chest x-ray films demon-strated a large air fluid level behind the heart.The heart and lungs were negative. There was

moderate tenderness to palpation in the left upper

quadrant. A nasogastric tube was inserted withthe recovery of 1,200 cc. of fluid and a largeamount of gas, affording great relief to the pa-

tient. Gastro-intestinal x-ray series performed soon

thereafter confirmed the presence of an obstructedparahiatal hernia (Fig. 4). The media and antrumof the stomach were herniated into the thoraciccavity in an upside-down position.

After three days of nasogastric suction andvigorous intravenous therapy, operation was per-

formed and the roentgenological findings were

corroborated. The hernial defect measuring 9.0 x6.0 cm. was easily closed after reducing the distaltwo-thirds of the stomach into the abdominal

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56 BEARDSLEY AND THOMPSON

TABLE 1

Classification

A. Incarcerated hiatal hernia with obstruction

1. Acute

a. Progressiveb. Fulminatingc. Intermittent

2. Chronic

B. Incarcerated hiatal hernia without obstruction

1. Chronic2. Intermittent

C. Strangulated hiatal hernia

1. Progressive2. Fulminating

cavity. A gastrostomy was also carried out. Abenign postoperative course ensued and when seen

one month later patient was asymptomatic.

Classification and SymptomatologyThe acutely obstructed hiatal hernia has

been discussed under various subject head-ings in the literature, but relatively littlehas been written about this disorder inthose reports dealing specifically with thecomplications of hiatal hernia.2 4 Scatteredcase reports have appeared in articles con-

cerning incarcerated and obstructed dia-phragmatic hernias, strangulated diaphrag-matic hernias, and gastric volvulus.5-7"12,15

Publications which refer to incarceratedor strangulated diaphragmatic hernias have

usually grouped traumatic cases, herniasthrough the foramina of Morgagni andBochdalek, and hiatal varieties together,with the traumatic in vast preponderance.3'8,11,15, 16 Gastric volvulus is usually thecause of acute obstruction within hiatalhernia, but articles on volvulus have notbeen primarily concerned with stressingthis as a complication of hiatal hernia. Asa result of these factors, the entity of theacutely obstructed hiatal hernia has notreceived proper emphasis and there hasbeen some confusion regarding terminol-ogy.

In describing the acutely obstructed hia-tal hernia, the word incarceration has

Aninals of SurgeryJanuary 1964

sometimes been used alone, implying ob-struction. This is incorrect since incarcer-ated hiatal hernia not infrequently occurswithout obstruction. We have used theterm incarceration regarding hiatal herniato signifly irreducibility as determined byclinical and roentgenographic means. Ithas been our experience that the acutelyobstructed cases are reduced at operationwithout difficulty and that adhesions aboutthe herniated organ are generally minimal,or absent. We would thus disagree withthose who believe that it is necessary forthe herniated organ to be bound down byadhesions in order to fulfill the require-ments for incarceration.'5The terms incarceration and strangula-

tion have sometimes been used interchange-ably, which, of course, is incorrect sincethe term strangulation should only be usedif the blood supply to the stomach is socompromised that resection must be seri-ously considered or actually carried out.Strangulation is most likely to occur in theorgano-axial type of gastric volvulus whenthe degree of rotation continues beyond180 degrees. Although it is relatively un-common, a number of cases have been re-ported, most often secondary to gastricvolvulus within para-esophageal hernia." 7'9, 13, 14 There was only one case of strangu-lation with perforation in the present se-ries. Although relatively rare in hiatal her-nia, it is a much more common occurrencein the traumatic type of diaphragmatichernia.Our classification of incarcerated and

strangulated hernia is presented in Table 1.Incarcerated Hiatal Hernia With Ob-

struction. The acute group with pro-gressive or fulminating symptoms is theone with which we are primarily con-cerned. We have treated 13 such caseswhose case reports are included in thispaper. Twelve were operated upon andone died on the medical service before thediagnosis was established. The acute ob-structive symptoms were secondary to a

ACUTELY OBSTRUCTED HIATAL HERNIA

FIG. 5 (Case 13). An example of chronic incarceration withotut obstruction.

gastric volvulus in 12 cases and to a torsion

of the stomach in the other case. All 12

cases of volvulus occurred within para-

esophageal hernias, or in a combination ofthe para-esophageal and sliding types andthe case of torsion within a huge slidinghiatal hernia. All except two of the patientsgave a history of sudden onset of epigastricand/or retrosternal pain followed by vom-

iting or retching, and in several the painradiated to the back. As a rule there was

very little frank vomiting but persistentretching was common. Three patientsnoted marked shortness of breath and one

was unable to give a history because ofpronounced orthopnea. Two gave a historyof marked weight loss. In this series mostof the patients had a steadily progressivecourse during which the clinical statusworsened until surgical intervention be-came a necessity and in others a fulminat-ing course was observed with rapid deteri-oration of their clinical condition. However,when it was possible to pass a Levin tube

beyond the point of obstruction, or in thecase of a partial volvulus, if the proximal

segment could be decompressed, the acute

symptoms often were relieved. Some gave

a past history of intermittent acute attackslasting from hours to days, but finally re-

solving spontaneously.There is another group of individuals

with sliding hiatal hernia who have devel-oped esophagitis, or stricture with second-ary shortening of the esophagus and re-

traction of the stomach into the chest.Obstruction, when present, is partial butvomiting and retching may occur. We haveincluded this group under the chronic sub-division of incarcerated hiatal hernia withobstruction for completeness, but have

made no attempt to include our experi-ence with this group.

Incarcerated Hiatal Hernia WithoutObstruction. In our experience incarcera-tion without obstruction is relatively com-

mon, and two case reports from this group

are included because of the striking x-ray

findings (Fig. 5, 6) and are particularlyremarkable in view of the relative lack ofsymptoms. Each patient has had a chroni-cally incarcerated para-esophageal hernia

Volume 159Number 1 57

BEARDSLEY AND THOMPSON Annals of SurgeryJanuary 1964

..'S; S}_ 2 00 .. ...,0Se:S tf.

FIG. 6 (Case 14). Another nonobstructed chronic incarceration. A good demonstration of themesentero-axial variety of volvulus.

containing inverted stomach as demon-strated by periodic x-ray studies over a

span of years.

Case 13. F. S., a 66-year-old woman, was ad-mitted on October 24, 1961, with a four-yearhistory of paroxysmal tachyeardia. She had beenfairly well controlled by digitalis until one monthprior to admission. At that time she beganto notice more frequent palpitations associatedwith generalized weakness and electrocardiogramshowed auricular fibrillation.

Examination on admission revealed a moder-ately obese female in no acute distress. The bloodpressure was 150/100, the apical rate 100 andirregular, and the radial rate 86 and irregular.A gastro-intestinal x-ray series demonstrated a

large para-esophageal hernia containing a com-

pletely inverted stomach (Fig. 5). Despite in-creasing the digitalis dosage and a trial of quini-dine, the fibrillation persisted intermittently. Itwas believed that the large hernia within thechest was the cause of the cardiac instability andtherefore a repair of the hiatal hernia was carriedout on the seventh hospital day. At operation thefindings of the gastro-intestinal x-rays were sub-stantiated and reduction of the stomach and repairof the hemia were carried out. The irregularrhythm persisted for six days postoperatively. Itthen disappeared and the patient was dischargedin excellent condition on the eighth postoperative

day. Regular follow up has failed to demonstratea recurrence of the irregular heart rate.

Case 14. A. S., a 48-year-old priest, was seen

on January 21, 1960, with a chief complaint ofpain in the lumbodorsal region for several years.

For five years he had had epigastric distress fol-lowing most meals. This had been somewhatworse during the past year. Recently, on twooccasions, he had been awakened at night witha sensation of smothering which was relieved aftersitting up. He had no heartbum and no loss ofweight. Except for an inguinal herniorrhaphy atthe age of 14, his past history was negative. Intra-venous pyelogram and x-rays of the spine were

negative. A gastro-intestinal x-ray series revealedthat the entire stomach was within the thoraciccavity and inverted (Fig. 6). There was no ob-struction and no intrinsic gastric lesion. Operationwas recommended but refused by the patient.

The other group of chronically incarcer-ated hiatal hernia without obstruction in-cludes those of the short esophagus typewith the proximal portion of the stomachretracted into the chest. Intermittent in-carceration may occur with either para-

esophageal or sliding varieties. On numer-

ous occasions, roentgenologists have notedthe entire stomach completely herniated

58

Volume 159Number 1

ACUTELY OBSTRUCTED HIATAL HERNIA 59TABLE 2. Summary of Cases with Obstriuction

Sex, Age Type Classification Results Cause of Death

1. F, 71 Para-esophageal Fulminating Living and well2. F, 75 Para-esophageal Progressive Living and well3. F, 79 Combined Progressive Died Cerebral vascular accident4. F, 75 Sliding Progressive Living and well5. F, 72 Para-esophageal Progressive Died Pulmonary embolism6. F, 67 Para-esophageal Progressive Died Cerebral vascular accident7. F, 76 Para-esophageal Progressive Living and well8. F, 83 Combined Progressive Died Pulmonary embolism9. F, 71 Para-esophageal Fulminating Living and well

10. F, 73 Para-esophageal Progressive Living and well11. F, 57 Para-esophageal Progressive Living and well12. F, 67 Para-esophageal Fulminating Died Gangrene and perforation of stomach,

mediastinitis, and peritonitis13. F, 59 Para-esophageal Fulminating Died Acute obstruction, pneumonia

(not operated)

into the chest only to find at later examina-tion that it had returned to the abdominalcavity.

Strangulated Hiatal Hernia. We havehad only one patient with strangulation ofthe stomach and perforation. In this groupthe course is usually steadily progressive,or fulminating. Although the history is sim-ilar to that of the incarcerated type, physi-cal findings are generally more striking andno doubt exists as to the severity of theillness. Once gangrene and perforation ofthe stomach have occurred with peritonitisand mediastinitis, irreversible shock is therule and the salvage rate is extremely small.

Case 15. L. F., a 63-year-old woman, was ad-mitted to the medical service on November 10,1962, complaining primarily of chest pain. Whileeating her evening meal on the day prior to ad-mission, she noted sudden inability to swallowwhich was almost immediately followed by vomit-ing and then by left lower chest pain. The pain,dull in quality, persisted and vomiting occurredeach time fluid or solid was ingested. A provi-sional admission diagnosis of coronary thrombosiswas made.

The examining physician noted on admissionthat the patient was not in acute distress. Herblood pressure was 150/100 and the pulse 100.Except for obesity, there were no significant find-ings. Complete blood count was normal and anelectrocardiogram demonstrated no evidence ofcoronary artery disease. A chest x-ray film showeda large air fluid level behind the heart and thisgave the initial clue to the correct diagnosis.

Shortly after admission the chest pain worsenedand the patient continued to vomit after takingfluids by mouth. A gastro-intestinal x-ray seriesperformed approximately 24 hours after admissiondemonstrated a completely obstructed parahiatalhernia with the distal stomach in the chest. Un-successful attempts were then made to pass aLevin tube into the stomach. The patient's dis-comfort increased, her pulse rate became rapid,her blood pressure dropped to hypotensive levels,and there was a rapid deterioration of her gen-eral condition. A surgical consultant who saw thepatient at this time advised immediate operation.

At operation, gas escaped on entering theperitoneal cavity and it became apparent thatthere was massive peritoneal contamination withgastric contents and barium. After copious irriga-tion, an irregular perforation measuring 2.5 X 7.5cm. in diameter was seen in the posterior wallof the stomach with a large area of surroundinggangrene. Because of the patient's precarious con-dition, it was believed unwise to repair the largehernial defect. The stomach was retumed to theabdominal cavity and after excision of the gan-grenous areas, the viable edges were reapproxi-mated and a gastrostomy performed.

The patient remained in poor condition follow-ing operation and despite energetic efforts to re-suscitate her, she died 24 hours following opera-tion. Postmortem examination demonstrated severeperitonitis, pleuritis, and mediastinitis.

Clinical and Roentgenological FindingsAll 13 patients in the incarcerated group

with acute obstruction were women, theoldest being 83 and the youngest 57 withan average age of 71. Although several

BEARDSLEY AND THOMPSON Annals of SurgeryJanuary 1964

ORGANO-AXIAL VOLVULUS

FIGURE 7.

appeared acutely ill at the time of admis-sion, the majority were not in serious straits,and none were in shock. Five of the 13patients were moderately dehydrated, butthere were no pronounced derangementsin electrolyte balance. Some degree ofemaciation was exhibited in two patients.Five had an essentially negative abdominalexamination and the remainder demon-strated a moderate degree of abdominaltenderness, usually localized in the epigas-trium. Two were noted to have abdominaldistention, one of which however also hadsmall bowel obstruction from pelvic ad-hesions, and none were found to have theconcavity in the epigastrium that has beenrecorded in cases in which the stomach hasmigrated into the chest. Examination of thechest revealed decreased breath sounds atthe left base in two patients and in twoothers bowel sounds were present withassociated hyperresonance. Rales at thebase of the lungs were detected in six pa-tients and in seven examination of thechest was reported as negative. The onlypatient who had a pleural effusion hadsevere associated pneumonia. Notation was

made in several charts that a Levin tubecould not be introduced into the stomach.Practically all patients had at least one

cardiovascular abnormality which is notunusual for the age group under considera-tion, and all but one had some abnormality

of the electrocardiogram, but no specificdefect was characteristic of the group.

Chest x-ray films generally demonstrateda simulated high diaphragm on the leftdue to herniated and distended stomachwith a gas fluid level. When barium was

introduced into the stomach, the resultantcontrast studies clearly demonstrated gas-

tric volvulus as the underlying cause of theobstruction. We have included contrast

films from six patients, four in the ob-structed group (Fig. 1-4) and two in thenonobstructed group (Fig. 5, 6). X-raysof two patients demonstrate the end resultsof rotation of the stomach through its longaxis (Fig. 3, 4), or the characteristic organo-

axial type of rotation (Fig. 7). In theseinstances the greater curvature has movedforward, upward, and to the right andthen backward, the greater curvature form-ing the upper border of the stomach. Rota-tion usually stops before going beyond 180degrees. Sometimes with migration, thestomach brings the gastrocolic omentumand transverse colon into the chest. Thisoccurred with four of our patients. Anexample of the less common type of vol-vulus or mesentero-axial type (Fig. 8) inwhich the stomach rotates in a clockwisedirection around an axis perpendicular tothe gastrohepatic ligament is shown inFigure 6. It will be noted that the pylorus

MESENTERO-AXIAL VOLVULUS

DIRECTION OF

ROTATION ALONG

ANT. OR POST. WALL* OF THE STOMACH

SUPERIORLY.

NN ~~~~~DIRECTION OF THE

DESCENT OF THE

FUNDUS OF THESTOMACH.

AXIS OF ROTATIONIS OBLIQUE.

FIGURE 8.

60

ACUTELY OBSTRUCTED HIATAL HERNIA

and antrum have ended up in front of theesophagus. Combinations of the two typesmay occur as is shown in Figure 1. Figure2 demonstrates a complete twisting of themid portion of the stomach or a gastrictorsion within a huge sliding hiatal hernia.In this case, small bowel obstruction was

also present, and the gastric torsion andobstruction can definitely be attributed tointra-abdominal pressure from dilatation ofthe small bowel. It was necessary to firstrelieve this before dealing with the gastricobstruction and repair of the large hiatalhernia.

Volvulus may be total with rotation ofthe entire stomach into the thoracic cavitygiving rise to obstruction at the esophago-

gastric junction, or partial in which only a

segment of the stomach, usually the antralend, lies above the diaphragm and the re-

mainder below, each with separate fluidlevels. In the latter, torsion of the stomachat the level of the hiatus is responsible forthe obstruction.

Management

The rationale of treatment of acutely ob-structed hiatal hernia follows the same gen-

eral pattern as for acutely obstructed her-

nias in other locations. An attempt is firstmade to decompress or reduce the hernialcontents, which, if unsuccessful by con-

servative means, must of necessity be ac-

complished by early operation.The fact that we are dealing with an

acute incarceration within the chest hasled many observers to conclude that thetransthoracic approach is mandatory. Ourexperience is to the contrary and all opera-tions in the present series have been per-formed by the abdominal route. The stom-ach and other incarcerated viscera havebeen returned to the abdominal cavity with-out the slightest difficulty and in only one

instance was it necessary to aspirate theintra-abdominal segment of a gastric vol-vulus in order to reduce the incarceratedstomach. One important advantage of the

abdominal approach is that the source ofgastric hemorrhage may be investigated as

in Case 9. Traumatic diaphragmatic herniaon the contrary, unless operated upon im-mediately following injury, should be ap-

proached through the chest since in theabsence of a sac the herniated structuresrapidly become adherent within the tho-racic cavity. If for any reason early opera-

tion is indicated the abdominal approach ispreferable, however, since during this earlyperiod there is no difficulty in reducing theherniated contents, and one must alwayshave in mind that intra-abdominal injuriesmay have to be dealt with. In as much as

we are frequently dealing with criticallyill, elderly patients, there may be instancesin which it is wiser to resort to gastropexy(Nissen 10) rather than meticulous repairof the hernial defect. Since the stomach isusually greatly distended, a gastrostomyis routinely employed to obviate the neces-

sity of prolonged Levin tube drainage. Thevalue of gastrostomy in elderly patients hasbeen recognized by many surgeons butwould seem to have a special place here.

In the present series, delay was the mostimportant single factor that contributed toa high mortality; first, delay in recommend-ing operation in patients who for years hadbeen known to have a large, symptomatichiatal hernia, but were continued on medi-cal management until obstruction occurred,and, second, delay in making a diagnosis ofobstruction after the patient had reachedthe hospital. In the former group, in theabsence of obstruction, repair of the herniawould have been a simple matter and ac-

complished at an earlier age. Delay in diag-nosis after the obstruction occurred was

responsible for two deaths in this series,both of whom were thought to be suffer-ing from acute coronary thrombosis. Al-though admittedly it may at times be dif-ficult to arrive at an early diagnosis, an

x-ray of the chest should usually alert us

to the possibility. Operation, however,should never be undertaken without a con-

Volume 159Number 1 61

62 BEARDSLEY AND THOMPSON Annals of SurgeryJanuary 1964

firmatory barium swallow since chronic in-carceration without obstruction is a rela-tively common finding and could confusethe picture in patients who might also besuffering from coronary thrombosis or otheracute conditions.The fact that two patients died of pul-

monary embolism and a third had clotsremoved from the femoral vein suggeststhat prophylactic femoral vein ligationmight be a wise precaution.

Summary

Thirteen cases of hiatal hernia with acuteobstruction are presented.

All patients were women, the oldest be-ing 83 and the youngest 57, with an aver-age age of 71.Of the 13 cases of obstruction, ten were

of the para-esophageal type, one sliding,and two a combination of the para-eso-phageal and sliding.A clinical classification, based on the

various types of incarceration and obstruc-tion, is submitted.The varieties of gastric volvulus responsi-

ble for the obstruction are described.Delay in recommending operation in pa-

tients known to have large symptomatichiatal hernias, and delay in establishing thecorrect diagnosis after the patient hadreached the hospital, were the most sig-nificant factors contributing to a high mor-tality.The diagnosis was most frequently con-

fused with acute coronary artery disease.All hernias were easily reduced by the

abdominal approach which would seem tohave many advantages over the thoracicoperation.

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