C A S E R E P O R T Open Access
Management of acute upside-down stomach
Tobias S Schiergens
, Michael N Thomas
, Thomas P Hüttl
and Wolfgang E Thasler
Background: 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 gastric outlet obstruction, advanced ischemia, gastric bleeding and perforation.
Case presentation: A 32-year-old male presented with acute intolerant epigastralgia and anterior chest pain
associated with acute onset of nausea and vomiting. He reported on a previous surgical intervention due to a
hiatal hernia. Chest radiography and computer tomography showed an incarcerated UDS. After immediate
esophago-gastroscopy, urgent laparoscopic reduction, repair with a 360° floppy Nissen fundoplication and insertion
of a gradually absorbable GORE® BIO-A®-mesh was performed.
Conclusion: Given the high risk of life-threatening complications of an incarcerated UDS as ischemia, gastric
perforation or severe bleeding, emergent surgery is indicated. In stable patients with acute presentation of large
paraesophageal hernia or UDS exhibiting acute mechanical gastric outlet obstruction, after esophago-gastroscopy
laparoscopic reduction and hernia repair followed by an anti-reflux procedure is suggested. However, in cases of
unstable patients open repair is the surgical method of choice. Here, we present an exceptionally challenging case
of a young patient with a giant recurrent hiatal hernia becoming clinically manifest in an incarcerated UDS.
Keywords: Upside-down stomach, Hiatal hernia, Paraesophageal hernia, Gastric incarceration, Gastric outlet obstruction,
Upside-down stomach (UDS) is the rarest type of hiatal
hernia (< 5%). It is characterized by herniation of the
entire stomach or most gastric portions into the posterior
mediastinum [1,2]. Both gastroesophageal junction and
parts of the stomach migrate intrathoracically, thus UDS
represents a large mixed type - sliding and paraesophageal
ferred to as type 4 hiatal hernia . Other intra-abdominal
organs can be involved in the herniation [5,6]. The patho-
physiology of hiatal hernias remains poorly understood.
Three pathogenic components are widely found in the
literature which can individually exist in different propor-
tions (1) increased intra-abdominal pressure (transdiaph-
ragmatic pressure gradient); (2) esophageal shortening
(fibrosis, vagal nerve stimulation); (3) widening of the dia-
phragmatic hiatus due to congenital or acquired structural
changes of periesophageal ligaments and muscular crura
of the hiatus . The latter include abnormalities of
elastin, collagens, and matrix metalloproteinases [7-10].
As hiatal and true paraesophageal hernia, UDS can
manifest itself clinically in a wide variety of symptoms
including substernal pain, heartburn, postprandial distress
and fullness, dysphagia, postprandial nausea and vomiting
[2,3]. They occur due to reflux related to the sliding
component and mechanically impaired gastric emptying,
thereby, the latter symptoms usually preponderate [4,11].
Chronic mucosal bleeding may cause anemia and is
ascribed to venous obstruction of the migrated stomach
. While UDS itself is a very rare condition it is associated
with a risk of incarceration as well as volvulus development.
These complications can cause acute gastric outlet ob-
struction and thereby present clinically as acute abdomen.
Further complications are acute and severe gastric bleeding,
ischemia and perforation. All of these complications
represent true emergencies as life-threatening conditions.
Prevalence of acute symptoms or incarceration in paraeso-
phageal hernia was reported to be 30,4% .
* Correspondence: Tobias.Schiergens@med.uni-muenchen.de
Department of Surgery, University of Munich, Campus Grosshadern, Munich,
Full list of author information is available at the end of the article
© 2013 Schiergens et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Schiergens et al. BMC Surgery 2013, 13:55
Once diagnosed, UDS should be surgically addressed
by reduction of the migrated stomach, excision of hernia
sac, and hiatal defect closure combined with an anti-reflux
procedure as 360° or partial fundoplication. Laparoscopic
repair provides benefits as reduced postoperative morbidity
and hospital stay. Even if asymptomatic a surgical interven-
tion is indicated as a conservative approach bears the
risk of a high mortality rate due to complications which
is significantly reduced by elective surgery [1,2,4,5,11].
In the light of only few series and cases reported, there
is no clear evidence from review of the current literature
for the management of acute paraesophageal hernia or
UDS as very rare conditions . In addition, there is an
ongoing controversial discussion about whether prothetic
reinforcement of the hiatus by mesh insertion is reasonable
and effective. In the face of high recurrence rates several
surgeons recommend the use of prosthetic meshes. How-
ever, many severe complications can be associated with
mesh implantation as perforation necessitating partial
esophagogastrectomy or acute erosive bleeding of the
abdominal aorta . In summary, there is still a consider-
able controversy regarding the routine mesh insertion and
the quality of evidence is very low.
Management of acute incarceration –case
A 32-year-old male presented to the emergency department
(ED) after acute thoraco-epigastric pain had set in after
dinner several hours before. On arrival in the ED, his
intolerant epigastralgia and anterior chest pain had
been associated with acute onset of nausea and vomiting.
The patient reported on having had recurrent substernal
pain and dysphagia as well as mild symptoms of reflux
which had persisted for more than a year. He reported on
a previous surgical intervention due to a hiatal hernia,
whereupon a anterior hemifundoplication had been
performed two years ago. Furthermore the patient had a
history of Ebstein’s anomaly which had been addressed by
a reconstruction of the tricuspid valve a year ago.
A naso-gastric tube was tried to be placed but pushing
it forward proved to be challenging and required repeated
attempts, which all turned out to be unsuccessful. On
admission the patient’s lactate level was mildly elevated
(2.4 mmol/L) and besides a slightly increased WBC
(12 / nL) unremarkable. Notably, no elevation of cardiac
enzymes was detected. Electrocardiogram on admission
showed sinus tachycardia, an incomplete right bundle
branch block and a distinct S1Q3-pattern. Echocardiog-
raphy revealed a normal left-ventricular ejection fraction,
however the right ventricle was dilated. Upright chest
radiography showed no subdiaphragmatic free air but vis-
ceral gas was seen in projection on the posterior mediasti-
num. Adjacent contrast-enhanced computer tomography
disclosed a giant hiatal hernia (Figure 1). Most portions of
the stomach and some of the greater omentum had
migrated into the posterior mediastinum, whereas parts of
the greater curvature appeared to be incarcerated in the
diaphragmatic hiatus. Immediate esophago-gastroscopy
showed a kinking-stenosis of the cardia and a stenosis
caused by the strangling diaphragm which could hardly be
passed. A 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.
Emergent surgery for reduction of the incarcerated
stomach and repair of the hiatal defect was performed
through five trocars evenly dispersed to the upper abdomen
(Figure 3). First, retracting the left liver lobe laparoscopic
reduction of the stomach and attached portions of the
greater omentum was conducted (Figure 3A–C) opening
the view to a giant hiatal defect (Figure 3D). After prepar-
ation of the diaphragmatic crura and the distal esophagus
preserving the rami of N. vagus a hiatoplasty was per-
formed by anterior and posterior approximation of the
diaphragmatic crura (Figure 3E–G). Given the fact of a
recurrent hernia and a very wide defect of approimately
8 cm, a gradually absorbable GORE® BIO-A®-mesh (W.L.
Gore & Associates Inc., Flagstaff, AZ) of biocompatible
synthetic polymers was inserted enlacing the gastro-
esophageal transition (Figure 3H–I). In a final step, a
360° floppy Nissen fundoplication was accomplished
(Figure 3J–L). Postoperatively the patient recovered very
well and was discharged five days later without any compli-
cation. He is to be followed up by the surgical outpatient
department and is presently free of any complaints.
Surgery for incarcerated paraesophageal hernia or UDS has
to be performed emergently as incarceration can become
irreversible and severe bleeding can occur due to distension
and vascular dilation. Moreover, ischemia and gastric
perforation are on the verge. However, there are no clear
evidence or existing guidelines on the management of acute
paraesophageal hernia or UDS. Referring to this, Bawahab
and colleagues have proposed algorithms based on the
results of a series of 20 patients with acute presentation
of paraesophageal hernia . From this data and our
experience, we suggest prompt open surgery in cases of
unstable patients [4,13]. However, from our point of view,
in case of gastric perforation or if there is any gastroscopic
evidence of advanced gastric ischemia in stable patients,
an initial laparoscopic approach is justifiable in case of
adequate expertise, otherwise emergent open repair is
suggested. In stable patients with acute presentation and
mechanical gastric outlet obstruction due to incarceration
Schiergens et al. BMC Surgery 2013, 13:55 Page 2 of 5
as in the presented case, emergent laparoscopic reduction
and repair is reasonable and prudent after urgent contrast-
enhanced computer tomography and decompressing gas-
troscopy. For patients with acute presentation but without
mechanical gastric obstruction and without gastric ischemia,
we suggest a semi-elective repair. In summary, laparoscopic
reduction and repair of acute paraesophageal hernia and
UDS was shown to be safe in patients without gastric per-
foration or ischemia as well as feasible with low morbidity
and mortality affording the benefits of minimally-invasive
Figure 1 Contrast-enhanced computer tomography. (A–C) Giant mixed-type hernia (upside-down stomach (S)) with an incarcerated portion
of the stomach (red arrows). (D) Visceral gas distribution seen from the 3D-reconstruction showing the proximal gastric portion (S) in the posterior
mediastinum (incarceration: red arrows).
Figure 2 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.
Schiergens et al. BMC Surgery 2013, 13:55 Page 3 of 5
surgery [4,13]. Moreover, studies have been published
reporting on percutaneous endoscopic gastrostomy (PEG)
as useful and feasible approach [15-18]. Tabo et al.
described a method facilitating the endoscopic reposition
of the stomach by inserting a gastric balloon and to fixate
the stomach subsequently applying the PEG-method
(intraabdominal fixation of the stomach by gastrostomy)
. It may be an effective approach in elderly patients as
the periprocedural risk is very low. In our young patient,
however, we decided in favor of a laparoscopic approach
repairing the hernia gate as sustainable therapy. In a series
of 40 patients we could show that laparoscopic treatment
of UDS is safe and highly effective using a laparoscopic
hiatoplasty and anterior hemifundoplication .
As to the diagnosis in the ED, a high index of suspicion
is essential when patients present acutely with epigastralgia
and symptoms of upper gastrointestinal obstruction indi-
cating mechanical gastric outlet obstruction. In our series,
5 of 50 patients with UDS (10%) presented with acute
symptoms, two of them with gastric incarceration, one
with upper gastrointestinal bleeding and one patient with
omentum incarceration . In another series of 147
patients, Allen and colleagues revealed that in 95% of
all patients with UDS symptoms occurred which were
primarily obstructive . Complications of hiatal hernia
are rarely considered in patients presenting with acute chest
or epigastric pain as well as acute gastric outlet obstruction.
Obstructive symptoms can range from mild nausea,
bloating, postprandial fullness, dysphagia, retching or
vomiting but rarely lead to the diagnosis in the ED. Hence,
there is a high risk to mis- and underdiagnose an incarcer-
ated UDS. Treatment as acute coronary syndrome (ACS)
can have fatal consequences as gastric perforation [19,20].
Although information and sensitivity are low, plain chest
radiography should be the first diagnostic tool whereby
other differential diagnoses can be considered or ruled
out. As a more reliable tool to work out the details of this
important differential diagnosis contrast-enhanced thora-
coabdominal computer tomography is suitable especially
for the detection of complications as well as the decision
for indicating surgery . Impossibility of naso-gastric
tube application as in our patient can be an evidence for
gastric incarceration or volvulus as it is described by
the Borchardt’sTriad consisting of the inability to pass
a naso-gastric tube, usually unproductive retching as well
as epigastric pain and distension . The presented
case shows the diagnostic challenge of acute presenta-
tion of paraesophageal hernia or UDS as they rarely
feature one’s lists of differential diagnoses of acute epi-
gastralgia or chest pain. Having confirmed the correct
diagnosis, immediate decompressing esophago-gastros-
copy and emergent surgery with reduction, hernia repair
and antireflux procedure are able to prevent life-threaten-
Figure 3 Laparoscopic reduction (A–D) and repair (E–G) of the incarcerated upside-down-stomach with insertion of a gradually absorbable
mesh (H–I) and accomplishment of a 360° floppy Nissen fundoplication (J–L).
Schiergens et al. BMC Surgery 2013, 13:55 Page 4 of 5
We present an exceptionally challenging case of a young
patient with a history of Ebstein’s anomaly and a giant
recurrent hiatal hernia becoming clinically manifest in an
incarcerated UDS. In spite of anterior hemifundoplication
two years ago the patient presented with this clinically and
patho-anatomically impressive recrudescence. A genetically
related common cause for cardiac and hiatal tissue defect
can be hypothesized but was not assessed for lack of
therapeutic consequences in this patient. However, given
the fact of a recurring and very large hernia in spite of pre-
vious surgical repair as well as the postulated underlying
tissue deficiency, we decided in favor of insertion of an
absorbable mesh for hiatal reinforcement and tension-free
complications associated with mesh implantation, we
are exceedingly reserved regarding routine use of meshes
and recommend thorough indication.
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 of this journal.
The authors declare that they have no competing interests.
TSS and WET collected the patient’s history data. TSS drafted the manuscript
with committed and dedicated review and discussion of MNT, TPH and WET.
All authors contributed substantially to the patient’s care and therapy. All
authors read and approved the final manuscript.
Department of Surgery, University of Munich, Campus Grosshadern, Munich,
Department of Surgery, Chirurgische Klinik
München-Bogenhausen, Munich, Germany.
Received: 14 March 2013 Accepted: 12 November 2013
Published: 15 November 2013
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Cite this article as: Schiergens et al.:Management of acute upside-down
stomach. BMC Surgery 2013 13:55.
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