Intrathoracic drainage of a perforated prepyloric gastric ulcer with a type II paraoesophageal hernia
© Pol et al; licensee BioMed Central Ltd. 2008
Received: 16 October 2008
Accepted: 08 December 2008
Published: 08 December 2008
With an incidence of less than 5%, type II paraesophageal hernias are one of the less common types of hiatal hernias. We report a case of a perforated prepyloric gastric ulcer which, due to a type II hiatus hernia, drained into the mediastinum.
A 61-year old Caucasian man presented with acute abdominal pain. On a conventional x-ray of the chest a large mediastinal air-fluid collection and free intra-abdominal air was seen. Additional computed tomography revealed a large intra-thoracic air-fluid collection with a type II paraesophageal hernia. An emergency upper midline laparotomy was performed and a perforated pre-pyloric gastric ulcer was treated with an omental patch repair. The patient fully recovered after 10 days and continues to do well.
Type II paraesophageal hernia is an uncommon diagnosis. The main risk is gastric volvulus and possible gastric torsion. Intrathoracic perforation of gastric ulcers due to a type II hiatus hernia is extremely rare and can be a diagnostic and treatment challenge.
Type II paraesophageal hernias are an uncommon diagnosis and occur in less than 5% of all hiatal hernias . The etiology is still unclear but previous surgical interventions, such as antireflux procedures or partial gastrectomies, have been recognized as a known risk factor. Due to progressive enlargement of the phrenoesophageal membrane, the greater curvature of the stomach tends to roll up into the thorax. Eventually, the whole stomach herniates, forming an upside-down intrathoracic stomach .
Most patients with a type II hernia are asymptomatic or have mild gastroesophageal reflux disease (GERD) and are diagnosed during upper gastrointestinal endoscopy. The most important complications are gastric volvulus or bleeding from gastric ulcerations or erosions (Cameron lesions) [2, 3]. The gold standard for gastric voluvus is open laparotomy with detorsion and anterior gastropexy, with or without a Nissen fundoplication .
Cameron lesions are linear gastric ulcers or erosions on the mucosal folds at the diaphragmatic impression in patients with a large hiatal herniam [3, 5]. Unlike the pre-pyloric ulcer in this case, Cameron ulcers are located on the lesser curvature of the stomach. Treatment is primarily medical with acid suppressants and prokinetic agents [2, 5].
To our knowledge only 5 case reports have been published reporting perforated gastric ulcers in combination with a paraesophageal hernia and just 2 cases reporting a perforated duodenal ulcer [6–12]. Normally, once a paraesophageal hernia is identified, it should be treated surgically with reduction of the herniated stomach with gastropexy to prevent reherniation and herniorraphy (or prosthetic mesh) of the diaphragma [13, 14]. Debate exists whether or not an antireflux procedure is necessary. In this case no herniorraphy or mesh repair was carried out due to the anticipated high risk of infection and abscess formation. In the author's opinion risk of complications due to additional procedures should be avoided in view of the known high mortality of a perforated gastric ulcer in combination with a type II hiatus hernia.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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