ABSTRACT: History of present illness: A 58-year-old male with history of smoking presented to the emergency department for productive cough, subjective fevers, shortness of breath, and pleuritic chest pain. Patient was discharged three days prior from another hospital where he was admitted for pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. He was discharged with prescriptions for antibiotics and steroids, which he did not fill. On exam, patient was afebrile and hemodynamically stable. Labs including respiratory syncytial virus and influenza panel were negative.

Significant findings: The two-view chest X-ray shows mild opacification of the bilateral lower lobes concerning for pneumonia (red arrows). Incidental retrocardiac opacity with air-fluid level consistent with large hiatal hernia is also observed (green arrow).

Discussion: A hiatal hernia (HH) is defined as a protrusion of abdominal contents into the thoracic cavity through the diaphragmatic esophageal hiatus.1 HHs can be congenital (1/3000 live births) or, more commonly, acquired.2 HHs are more common in women than in men, and their frequency increases with age, from 10% in patients younger than 40 to 70% in patients over 70 years old.1,3 Acquired HHs can be classified as sliding, paraesophageal, or mixed. Sliding hernias make up greater than 90% of all HHs and occur when the abdominal portion of the esophagus and the cardia & fundus of the stomach slide superiorly through the esophageal hiatus.1 Sliding hernias are clinically significant due to their association with reflux disease.1 Paraesophageal hernias make up less than 10% of all HHs and only involve the stomach fundus passing superiorly into the thoracic cavity.1 Paraesophageal hernias tend to enlarge over time potentially leading to incarceration and subsequent strangulation or perforation.4

Patients with HHs can be asymptomatic or have symptoms such as epigastric fullness, postprandial distress, regurgitation, nausea, chest pain, or cough.4,5 Radiography studies, especially an upper GI barium series, are the preferred examination method to diagnosing HHs with a sensitivity of 77%.6 The primary diagnostic finding is a retrocardiac air-fluid level located within a paraesophageal hernia or intrathoracic stomach.1 Asymptomatic hernias may not require treatment. HH with reflux disease can be managed medically. Symptomatic HHs and paraesophageal hernias might require surgical intervention; thus surgical consultation is recommended.4

In this case, the chest X-ray was concerning for pneumonia, and a large, incidental hiatal hernia was also appreciated. Patient was started on antibiotics for the pneumonia and admitted to internal medicine. The hiatal hernia was not operated on because the patient was asymptomatic.

Topics: Hiatal hernia, sliding hernia, paraesophageal hernia, retrocardiac air bubble.

ABSTRACT: History of present illness: A 31-year-old female with history of sigmoid volvulus status post sigmoidectomy 2 years prior presented to the emergency department with 1-week history of diffuse, crampy abdominal pain. In the 24 hours prior to her arrival, patient stated that her abdominal pain acutely worsened and was accompanied with decreased stool output and non-bloody, non-bilious emesis. She denied any fever, chills, weight loss, chest pain, or shortness of breath.

Significant findings: Computed tomography (CT) of the abdomen and pelvis was obtained revealing a colonic volvulus in the left mid to upper abdomen (blue arrow) involving the distal transverse colon and descending colon, with gaseous colonic distention to 8.5 cm (red arrow). The characteristic “whirl pattern” is also present (yellow arrow). These findings are suggestive of a high-grade colonic obstruction. It was without evidence of pneumoperitoneum, pneumatosis, or drainable collection. Of note, a 3.6 cm dermoid tumor is also observable in the left adnexa (green arrow).

Discussion: A colonic volvulus refers to the twisting of a portion of the colon, most often the sigmoid, in a manner leading to obstruction and potential ischemia and gangrene.1 Colonic volvulus is responsible for approximately 15% of all large bowel obstructions in the United States.1 The mortality associated with this condition is less than 10% in patients who have not developed gangrene, but can be as high as 60% if gangrene is present.2 A sigmoid volvulus occurs when the sigmoid colon is elongated, leading to a redundant loop which rotates around its mesocolon.3 This condition is most common in the elderly with a mean age of 70 years at presentation.4 Institutionalized patients with neuropsychiatric disorders and patients in nursing homes are at the highest risk as these populations experience prolonged recumbency and chronic constipation, which are both highly associated with sigmoid volvulus development.1

Patients with sigmoid volvulus present with slow onset and progressive abdominal pain, nausea, abdominal distention, and constipation. Vomiting is also common but normally occurs several days after the initial onset of pain.5 Computed tomography is the preferred method of diagnosis with a sensitivity of 71%.6 Diagnostic findings include a "whirl pattern," which is caused by the twisting of the sigmoid colon around its mesocolon, and a "bird-beak" appearance of the afferent and efferent colonic segments.7 Treatment of a sigmoid volvulus begins with a flexible sigmoidoscopy for decompression and detorsion, followed by definitive surgery to prevent recurrence.4 Without definitive surgery, recurrence rates of sigmoid volvulus has been reported as high as 90%.1 In this case, gastroenterology was consulted and patient was taken to the endoscopy suite for decompression and detorsion.

Topics: Sigmoid volvulus, large bowel obstruction, colonic volvulus.

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