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Esophago-gastroscopy. (A) Distended stomach migrated intrathoracically exhibiting the stenosis caused by the strangling diaphragm which could hardly be passed endoscopically. (B) Gastric mucosa appearing unremarkable aside from minor petechial bleedings.

Esophago-gastroscopy. (A) Distended stomach migrated intrathoracically exhibiting the stenosis caused by the strangling diaphragm which could hardly be passed endoscopically. (B) Gastric mucosa appearing unremarkable aside from minor petechial bleedings.

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Upside-down stomach (UDS) is characterized by herniation of the entire stomach or most gastric portions into the posterior mediastinum. Symptoms may vary heavily as they are related to reflux and mechanically impaired gastric emptying. UDS is associated with a risk of incarceration and volvulus development which both might be complicated by acute g...

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... naso-gastric tube was then positioned endo- scopically and food residue and gas were sucked off for therapeutic decompression of the incarcerated stomach. Altogether mucosa appeared unremarkable and there were no signs of ischemia or restrained perfusion (Figure 2). After endoscopy the patient's complains were attenuated but not resolved. ...

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Paraesophageal hernia with intrathoracic mesentericoaxial type of gastric volvulus is a rare clinical entity. The rotation occurs because of the idiopathic relaxation of the gastric ligaments and ascent of the stomach adjacent to the oesophagus through the hiatus defect, while the gastroesophageal junction remains in the abdomen. The open approach...

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... For instance, Umemura et al. [23] pointed out that the UDS is usually caused by organoaxial volvulus, referencing a study by Gryglewski et al. [25], in which they present a case of 'incarcerated UDS' that is quite reminiscent of the cases in our series. According to some authors, UDS is a type of mixed (i.e., type 3) HH, whilst for others it is a different type of hernia [26]. Other authors have described it as a 'type of large paraesophageal hernia' [27]. ...
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Background: Gastric volvulus (GV) is a life-threatening emergency condition that prompts emergent surgical management. With the advent of high-resolution computed tomography (CT), the role of radiologists in its diagnosis has become essential. Although many cases of GV have been described in the literature, its pathophysiology is still poorly understood. In addition, there is substantial terminological confusion with associated entities such as paraesophageal hernia, upside-down stomach, organo-axial or chronic GV. Methods: We conducted a retrospective review of clinical, radiological findings and other relevant data for seven patients with previous radiological diagnoses of a large hiatus hernia who presented with acute GV to the emergency department of our institution. We report data on age, sex, medical history, clinical presentation, imaging, treatment and outcomes for each case. Results: The CT findings at acute presentation showed the antrum lying above the diaphragm and dilated fundus below the diaphragm. By comparing the position of the stomach at acute presentation with previous imaging examinations, we confirmed a hypothesis put forward by a few authors decades ago that re-herniation of the gastric fundus into the abdomen is a common pathophysiologic trigger leading to acute GV. This hypothesis has not been supported by modern imaging examinations. Conclusions: We have provided imaging evidence supporting that the pathophysiology of many GVs is based on caudal re-descent of hiatal hernia into the abdominal cavity. Given the terminological disparity used in the literature in this context, we believe it appropriate to introduce and extend the term 'back-and-forth stomach' to refer to this type of GV.
... However, this is often difficult because a kinking stenosis of the cardia (caused by organoaxial rotation of the stomach) or a stenosis caused by the strangling diaphragm may be present, preventing passage of the tube into the stomach. 5 Although intra-arrest esophagogastroscopy may be considered, it is seldom readily available in the ED. In addition, it carries the risk of increased inflation of the thoracic part of the stomach, with further cardiac compromise. ...
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During cardiopulmonary resuscitation, one of the first priorities after establishing basic and advanced life support is to identify the cause of the arrest. We present a rare case of cardiac arrest due to a decreased venous return from mediastinal shift caused by a paraesophageal hernia with an incarcerated thoracic gastric volvulus, which was treated by percutaneous gastrostomy.
... [20] As well as hiatal hernias, UDS can give a wide variety of symptoms such as retrosternal pain, heartburn, post-prandial fullness, dysphagia, nausea, vomiting, anemia and masseffect symptoms. [22,23] According to Singleton, gastric volvulus can be classified as organoaxial (59%), when the stomach rotates around the pylorus and the gastroesophageal junction and mesenteroaxial (29%), when the stomach rotates along the longitudinal line parallel to the small gastric curve, or mixed (12%). [1,19,21] The gastric volvulus, clinically, can present itself as an acute abdomen or as a chronic intermittent recurrent pathology. ...
... Chest x-ray highlights the presence of abdominal viscera that have risen in the chest. [3,23] Other tests, often not performed in acute, are the barium contrast studium and digestive endoscopy. [4] The Chest and Abdomen CT allows to have an immediate diagnosis, to know the extent of the herniation, to put the right surgical indication, facilitating so preoperative planning. ...
... [4] The Chest and Abdomen CT allows to have an immediate diagnosis, to know the extent of the herniation, to put the right surgical indication, facilitating so preoperative planning. [1,3,4,23] The traditional treatment is an immediate surgical intervention to derotate the stomach and to prevent vascular insufficiency. In the presence of necrosis or gastric perforation, resection should be performed. ...
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Introduction The gastric volvulus is a rare condition in which the stomach, or part of it, rotates on its axis, for over 180°, constituting a surgical emergency. Even more rare is gastro-gastric intussusception. A delay in their diagnosis and treatment can have fatal consequences Presentation of case An 82-year-old woman was admitted to the Surgery Unit with a two-day history of abdominal pain associated at first with coffee vomiting and, subsequently, with unproductive retching and oligoanuria. Physical examination showed severe dehydration, fever, at the abdominal level, palpation caused a marked tenderness of all quadrants, with signs of peritonism. Laboratory test showed showed neutrophilic hyperleukocytosis and high C reactive protein level. Abdominal computed tomography revealed an acute intrathoracic gastric volvulus and a gastrogastric intussuception. The patient was submitted to exploratory laparotomy, subtotal gastrectomy with Roux en Y anastomosis and simple plastic of the esophageal hiatus. At the end of the surgery, however, the patient died of your septic shock. Discussion The traditional treatment for a patient with acute gastric volvulus is an immediate surgical intervention to derotate the stomach and prevent vascular insufficiency. In the presence of necrosis or gastric perforation, resection should be performed. The few cases of gastrogastric intussusception described in the literature have been treated with sub-total gastrectomy and gastro-jejunal anastomosis. Any delay in diagnosis and treatment can prove fatal. Conclusion Intrathoracic Gastric Volvulus and, even more, retrograde gastrointestinal intussusception are very rare pathologies, difficult to diagnose.
... Surgical emergency treatment provides the reduction of the migrated stomach with the excision of the hernia sac. The hiatal defect closure (direct or with mesh) may be followed by an anti-reflux procedure (according to Toupet or Nissen) or gastropexy [2,10,15,16]. Nevertheless, prosthetic mesh reinforcement is overall accepted since its introduction has reduced the risk of recurrences [15,17,18]. ...
... The hiatal defect closure (direct or with mesh) may be followed by an anti-reflux procedure (according to Toupet or Nissen) or gastropexy [2,10,15,16]. Nevertheless, prosthetic mesh reinforcement is overall accepted since its introduction has reduced the risk of recurrences [15,17,18]. Particular care is mandatory during gastric wall handling. ...
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Background: Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature. Methods: During 10 years (December 2009-December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review. Results: The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences. Conclusion: Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations.
... The rarest type of hiatal hernia is the upside-down stomach (Fig. 16), with a complete or nearly Posteroanterior (a) and lateral (b) chest X-ray showed a large herniation of almost the whole stomach into the posterior mediastinum in a 78-year-old female patient (arrows). In the enhanced computed tomography in coronal (c) and axial (d) images, the entire extent of the gastric herniation with partial rotation is demarked (arrows) complete herniation of the stomach into the posterior mediastinum [50,51]. Other minor forms of migration are hiatal hernia at the gastro-esophageal junction, paraesophageal hernia of a minor part of the stomach, or a combination of both [52,53]. ...
... Also, an additional herniation beside the upside-down stomach in form of an additional paraesophageal herniation through the hiatus or a secondary gap is possible [54]. Various pathomechanisms or a combination of them are possible for an upside-down stomach: besides increased intraabdominal pressure, trauma including widening of the diaphragmatic hiatus or shortening of the esophagus are potential reasons [51,54]. The stomach is usually fixed in the upper abdomen without the possibility of migration or volvulus. ...
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The imaging evaluation of the abdomen is of crucial importance for every radiologist. In addition to ultrasound, conventional radiographs and contrast-enhanced computed tomography (CT) are the most common imaging procedures in the abdominal region. Numerous pathognomonic signs should be known in this context by every radiologist. Radiographs of the abdomen are an often used first step in radiologic imaging, while CT examinations are carried out for further differentiation, in oncological settings and in time-critical emergency situations. A fast and clear assignment of these signs to a specific disease is the basis for a correct diagnosis. This pictorial review describes the most common pathognomonic signs in abdominal imaging. The knowledge of these pictograms is therefore essential for radiologists interested in abdominal medicine and should also be addressed in training and further education.
... Many reports support this statement. 11,14 There is no disputing the surgical indication for symptoms of gastric outlet obstruction and torsion. ...
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The majority of large hiatal hernias are paraesophageal hiatal hernias (PEH). Once prolapse of the stomach to the chest cavity reaches a high degree, it is called an intrathoracic stomach. More than 25 years have elapsed since laparoscopic surgery was carried out as minimally invasive surgery for PEH. The feasibility and safety thereof has nearly been established. PEH may cause serious complications such as strangulation and perforation. The outcome of elective repair of PEH is better than emergent repair, so we should carry out elective repair as much as possible. Although not a major clinical problem, following PEH repair the rate of anatomical recurrence increases with age. In order to reduce the recurrence rate, mesh reinforcement by crural repair has been widely performed. Although this improves the short‐term outcomes, the long‐term outcomes are unclear. For PEH repair, fundoplication and gastropexy are believed desirable. We should select the procedure associated with a lower incidence of dysphagia and so on following surgery. While relaxing incision is useful for primary tension‐free closure, it has not contributed to improvement in the recurrence rate. This work describes several recent topics about minimally invasive surgery for paraesophageal hiatal hernia, especially, large hiatal hernia and intrathoracic stomach.
... Se trata de una patología poco frecuente, siendo una variedad muy rara de las hernias paraesofágicas y representando una incidencia del 5 % del total de las hernias internas según lo reportado en la literatura médica. Por ello, presentamos el caso clínico manejado en nuestra institución junto a una amplia revisión de la literatura 4,7,8 . ...
... También se ha relacionado con trauma cerrado o penetrante a nivel toracoabdominal con compromiso diafragmático, obesidad, envejecimiento y escoliosis. Sin embargo, nuestro paciente no presentaba ninguno de estos factores predisponentes 3,4,19,20 . La fisiopatología de esta entidad está dada básicamente por tres componentes interrelacionados. ...
... La manifestación clásica del vólvulo gástrico es la tríada de Borchardt presentada en la tabla II 3,10 . También pueden tener una presentación aguda entre el 10 % y el 30 % de los casos con sangrado, abdomen agudo, obstrucción intestinal, inestabilidad hemodinámica, isquemia, perforación del estómago y sepsis 4,7 . ...
Article
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Resumen Introducción: El estómago intratorácico volvulado (EIV) es un tipo de hernia hiatal caracterizada por la presencia de una gran porción gástrica en el mediastino. Patología de gran importancia ya que de no operarse oportunamente puede conllevar un mal pronóstico. Caso clínico: Paciente femenina de 56 años con epigastralgia aguda e intolerancia a la vía oral asociada a náuseas y múltiples episodios eméticos de contenido alimentario. Sin antecedentes médicos o quirúrgicos relevantes, endoscopia de vías digestivas altas y una radiografía de tórax en donde reportan un posible vólvulo gástrico con un ensanchamien-to del mediastino inferior y presencia de la cámara gástrica a nivel del tórax. Discusión: Debido a que un estómago herniado volvulado a nivel del tórax presenta un alto riesgo de complica-ciones, está, en estos infrecuentes casos, indicada la cirugía de urgencia. En pacientes clínicamente estables con una evolución reciente de obstrucción gástrica se sugiere el abordaje laparoscópico para su reducción y reparación de la hernia. Sin embargo, en casos de pacientes inestables, la reparación abierta es el método quirúrgico de elección. Palabras clave: Hernia hiatal mixta, hernia paraesofágica, incarceración gástrica intratorácica, obstrucción gástrica intratorácica, vólvulo gástrico intratorácico, hernia hiatal gigante. Abstract Introduction: A volvulated intrathoracic stomach (IVD) is a hiatal hernia type characterized by the presence of a large portion of the stomach ascended into the mediastinum. It is considered to be a pathology of great importance because of the high probability of mortality associated when not diagnosed and operated promptly. Case report: A 56-year-old female patient presents with acute epigastric pain associated with nausea and multiple emetic episodes of food content. She did not have any relevant medical or surgical history. Endoscopy of the upper digestive tract and a chest x-ray were performed and reported a possible gastric volvulus and a widening of the lower mediastinum associates to the presence of the gastric chamber inside the thoracic cavity. Discussion: Because of the high risk of complications, the diagnosis of an intrathoracic gastric volvulus indicates emergency surgery. In clinically stable patients with an acute presentation of gastric obstruction, laparoscopic approach is suggested for its reduction and hernia repair. However, in cases of unstable patients, open surgery should be considered the method of choice.
... Se trata de una patología poco frecuente, siendo una variedad muy rara de las hernias paraesofágicas y representando una incidencia del 5 % del total de las hernias internas según lo reportado en la literatura médica. Por ello, presentamos el caso clínico manejado en nuestra institución junto a una amplia revisión de la literatura 4,7,8 . ...
... También se ha relacionado con trauma cerrado o penetrante a nivel toracoabdominal con compromiso diafragmático, obesidad, envejecimiento y escoliosis. Sin embargo, nuestro paciente no presentaba ninguno de estos factores predisponentes 3,4,19,20 . La fisiopatología de esta entidad está dada básicamente por tres componentes interrelacionados. ...
... La manifestación clásica del vólvulo gástrico es la tríada de Borchardt presentada en la tabla II 3,10 . También pueden tener una presentación aguda entre el 10 % y el 30 % de los casos con sangrado, abdomen agudo, obstrucción intestinal, inestabilidad hemodinámica, isquemia, perforación del estómago y sepsis 4,7 . ...
Article
Full-text available
Introducción: El estómago intratorácico volvulado (EIV) es un tipo de hernia hiatal caracterizada por la presencia de una gran porción gástrica en el mediastino. Patología de gran importancia ya que de no operarse oportunamente puede conllevar un mal pronóstico.Caso clínico: Paciente femenina de 56 años con epigastralgia aguda e intolerancia a la vía oral asociada a náuseas y múltiples episodios eméticos de contenido alimentario. Sin antecedentes médicos o quirúrgicos relevantes, endoscopia de vías digestivas altas y una radiografía de tórax en donde reportan un posible vólvulo gástrico con un ensanchamiento del mediastino inferior y presencia de la cámara gástrica a nivel del tórax.Discusión: Debido a que un estómago herniado volvulado a nivel del tórax presenta un alto riesgo de complicaciones, está, en estos infrecuentes casos, indicada la cirugía de urgencia. En pacientes clínicamente estables con una evolución reciente de obstrucción gástrica se sugiere el abordaje laparoscópico para su reducción y reparación de la hernia. Sin embargo, en casos de pacientes inestables, la reparación abierta es el método quirúrgico de elección.
... hiatus in the diaphragm, is a heterogenous clinical entity that can present with a wide variety of symptoms [1][2][3][4][5][6]. The nature of HH is complicated by the multifactorial etiology of the condition (anatomic, environmental and genetic) [3,5,[7][8][9][10][11]. Acquired or congenital structural changes of the ligamentous attachments and the muscular crura of the hiatus, which are responsible for the maintenance of the normal position of the gastroesophageal junction (GEJ), can lead to the development of HH. ...
... and esophageal shortening (from fibrosis and vagal nerve stimulation), and their involvement in the development of HH constitutes the basis of the relevant theories of its pathogenesis [1][2][3][5][6][7][9][10][11][12]. No single theory, however, has identified a definitive cause of the development of HH [10]. ...
... HH affect more than 10% of the general population [2][3][4][5][6]11]. The types of HH II-IV, which are the least common (~5% of cases), consist of a true hernial sac, and are all varieties of paraesophageal hernia (PEH) [2,4,6,10]. ...
Article
Background The intrathoracic or upside-down stomach (UDS) is associated with the risk of incarceration and volvulus, which can be complicated by acute gastric obstruction and strangulation, leading to sepsis. Two cases of complicated UDS are reported, with a review of the relevant literature, to highlight the diagnostic challenges and management of this devastating condition. Methodology Two case reports are presented and the literature from 1995 to the present is reviewed regarding the etiology, incidence, presentation, diagnosis and treatment of complicated large paraesophageal hernia (PEH) and acute UDS. Description of Cases Two patients with cases of known large PEH and severe comorbidities, a man aged 88 years (case I) and a woman aged 78 years (case II), underwent emergency operation for volvulus and strangulation of UDS, after intense resuscitation. Case I had a prepyloric lesion revealed by gastroscopy. Case II also had an incarcerated abdominal incisional hernia producing bowel obstruction, and was in septic shock. X-ray and CT of the chest and abdomen helped the diagnosis of complicated PEH. Operative findings: In Case I, the entire stomach was found in the mediastinum with volvulus and distal ischemia; distal gastrectomy, gastrojejunostomy, cruroraphy and fundopexy were performed. In Case II, after freeing the incarcerated viable bowel, UDS was identified in the mediastinum, with ischemic antrum and necrotic, ruptured gastric fundus; total gastrectomy was performed with esophageal and duodenal stapling, and a feeding jejunostomy was constructed. Both patients were transferred intubated to the intensive care unit (ICU). Case I was extubated on day 4 and discharged on day 28; histology revealed antral ischemia and obstructive prepyloric pT2 adenocarcinoma. Case II was never stabilized, and died 50 hours after surgery; histology demonstrated gastric necrosis. Conclusions Obstructive conditions distal to large PEHs may cause life-threatening complications in the contents of the hernial sac. In patients who are in unstable condition, with complicated large PEH or UDS with gastric compromise, emergency open surgery is required for reduction and resection of the necrotic parts of the stomach and possibly other organs. In other patients, who respond well to resuscitation after endoscopic gastric decompression, semi-urgent or early elective repair may be programmed.
... Mezi příčiny tohoto stavu patří zvýšení nitrobřišního tlaku, zkrácení jícnu a rozšíření hiatus oesophageus. Rizikovými faktory pro rozvoj UDS jsou preexistující poškození hiatus oesophageus a onemocnění pojiva [1,2]. ...
... Klinické projevy UDS se mohou pohybovat na škále od postprandiální nevolnosti přes zvracení, pyrózu a dysfagii až po bolest za sternem či v epigastriu [1][2][3][4]. Bylo ovšem popsáno také několik případů UDS s příznaky odpovídajícími akutnímu koronárnímu syndromu [3][4][5]. Třicet procent nemocných s UDS má sklon k chronickému i akutnímu gastrointestinálnímu krvácení, k perforaci žaludku, uskřinutí či volvulu, přičemž tyto komplikace zvyšují jejich mortalitu [1][2][3][4]. ...
... Bylo ovšem popsáno také několik případů UDS s příznaky odpovídajícími akutnímu koronárnímu syndromu [3][4][5]. Třicet procent nemocných s UDS má sklon k chronickému i akutnímu gastrointestinálnímu krvácení, k perforaci žaludku, uskřinutí či volvulu, přičemž tyto komplikace zvyšují jejich mortalitu [1][2][3][4]. ...
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Upside down stomach (UDS) as a severe form of hiatal hernia has various clinical scenarios. Patients could be asymptomatic or present with haemodynamic collapse due to mechanical compression of the mediastinum. We herein present a case of 71-year-old woman referred to our clinic due to acute coronary syndrome with acute onset of heart failure, which was treated accordingly. Throughout the diagnostic and therapeutic process, a diagnosis of an incarcerated UDS was established as a trigger of her symptoms. An acute surgery was performed. Despite complications in the post-op period the patient recovered successfully and was referred to a rehabilitation facility for further therapy.