ArticlePDF Available

Management of acute upside-down stomach

  • Red Cross Hospital Munich, Germany

Abstract and Figures

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. 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[degree sign] floppy Nissen fundoplication and insertion of a gradually absorbable GORE(R) BIO-A(R)-mesh was performed. 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.
Content may be subject to copyright.
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,
Gastric volvulus
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 [4]. 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 [7]. 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
[2]. 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% [12].
* Correspondence:
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 (, 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 [13]. 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 [14]. 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 Ebsteins 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 patients 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 patients 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 3AC) 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 3EG). 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 3HI). In a final step, a
360° floppy Nissen fundoplication was accomplished
(Figure 3JL). 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 [13]. 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. (AC) 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)
[18]. 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 [4].
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 [4]. In another series of 147
patients, Allen and colleagues revealed that in 95% of
all patients with UDS symptoms occurred which were
primarily obstructive [11]. 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 [19]. 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 BorchardtsTriad consisting of the inability to pass
a naso-gastric tube, usually unproductive retching as well
as epigastric pain and distension [21]. The presented
case shows the diagnostic challenge of acute presenta-
tion of paraesophageal hernia or UDS as they rarely
feature ones 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-
ing complications.
Figure 3 Laparoscopic reduction (AD) and repair (EG) of the incarcerated upside-down-stomach with insertion of a gradually absorbable
mesh (HI) and accomplishment of a 360° floppy Nissen fundoplication (JL).
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 Ebsteins 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.
Competing interests
The authors declare that they have no competing interests.
TSS and WET collected the patients history data. TSS drafted the manuscript
with committed and dedicated review and discussion of MNT, TPH and WET.
All authors contributed substantially to the patients care and therapy. All
authors read and approved the final manuscript.
Author details
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
1. Hill LD, Tobias JA: Paraesophageal hernia. Arch Surg 1968, 96:735744.
2. Krahenbuhl L, Schafer M, Farhadi J, Renzulli P, Seiler CA, Buchler
MW: Laparoscopic treatment of large paraesophageal hernia
with totally intrathoracic stomach. J Am Coll Surg 1998,
3. Wo JM, Branum GD, Hunter JG, Trus TN, Mauren SJ, Waring JP: Clinical
features of type III (mixed) paraesophageal hernia. Am J Gastroenterol
1996, 91:914916.
4. Obeidat FW, Lang RA, Knauf A, Thomas MN, Huttl TK, Zugel NP, et al:
Laparoscopic anterior hemifundoplication and hiatoplasty for the
treatment of upside-down stomach: mid- and long-term results after
40 patients. Surg Endosc 2011, 25:22302235.
5. Skinner DB, Belsey RH: Surgical management of esophageal reflux and
hiatus hernia. Long-term results with 1,030 patients. J Thorac Cardiovasc
Surg 1967, 53:3354.
6. Landreneau RJ, Del PM, Santos R: Management of paraesophageal
hernias. Surg Clin North Am 2005, 85:411432.
7. Weber C, Davis CS, Shankaran V, Fisichella PM: Hiatal hernias: a review of
the pathophysiologic theories and implication for research. Surg Endosc
2011, 25:31493153.
8. Curci JA, Melman LM, Thompson RW, Soper NJ, Matthews BD: Elastic fiber
depletion in the supporting ligaments of the gastroesophageal junction:
a structural basis for the development of hiatal hernia. J Am Coll Surg
2008, 207:191196.
9. Asling B, Jirholt J, Hammond P, Knutsson M, Walentinsson A, Davidson G, et al:
Collagen type III alpha I is a gastro-oesophageal reflux disease susceptibility
gene and a male risk factor for hiatus hernia. Gut 2009, 58:10631069.
10. Melman L, Chisholm PR, Curci JA, Arif B, Pierce R, Jenkins ED, et al:
Differential regulation of MMP-2 in the gastrohepatic ligament of the
gastroesophageal junction. Surg Endosc 2010, 24:15621565.
11. Allen MS, Trastek VF, Deschamps C, Pairolero PC: Intrathoracic stomach.
Presentation and results of operation. J Thorac Cardiovasc Surg 1993,
12. Hill LD: Incarcerated paraesophageal hernia. A surgical emergency.
Am J Surg 1973, 126:286291.
13. Bawahab M, Mitchell P, Church N, Debru E: Management of acute
paraesophageal hernia. Surg Endosc 2009, 23:255259.
14. Zugel N, Lang RA, Kox M, Huttl TP: Severe complication of laparoscopic
mesh hiatoplasty for paraesophageal hernia. Surg Endosc 2009,
15. Criblez DH: Percutaneous endoscopic gastrostomy to treat upside-down
stomach before stent insertion in a patient with distal esophageal
carcinoma. Am J Gastroenterol 1998, 93:19381941.
16. Januschowski R: Endoscopic repositioning of the upside-down stomach
and its fixation by percutaneous endoscopic gastrostomy. Dtsch Med
Wochenschr 1996, 121:12611264.
17. Lukovich P, Dudas I, Tari K, Jonas A, Herczeg G: PEG fixation of an upside-down
stomach using a flexible endoscope: case report and review of the literature.
Surg Laparosc Endosc Percutan Tech 2013, 23:e65e69.
18. Tabo T, Hayashi H, Umeyama S, Yoshida M, Onodera H: Balloon
repositioning of intrathoracic upside-down stomach and fixation by
percutaneous endoscopic gastrostomy. J Am Coll Surg 2003, 197:868871.
19. Chang CC, Tseng CL, Chang YC: A surgical emergency due to an
incarcerated paraesophageal hernia. Am J Emerg Med 2009, 27:135. el-3.
20. Trainor D, Duffy M, Kennedy A, Glover P, Mullan B: Gastric perforation
secondary to incarcerated hiatus hernia: an important differential in the
diagnosis of central crushing chest pain. Emerg Med J 2007, 24:603604.
21. Johnson JA III, Thompson AR: Gastric volvulus and the upside-down
stomach. J Miss State Med Assoc 1994, 35:14.
Cite this article as: Schiergens et al.:Management of acute upside-down
stomach. BMC Surgery 2013 13:55.
Submit your next manuscript to BioMed Central
and take full advantage of:
Convenient online submission
Thorough peer review
No space constraints or color figure charges
Immediate publication on acceptance
Inclusion in PubMed, CAS, Scopus and Google Scholar
Research which is freely available for redistribution
Submit your manuscript at
Schiergens et al. BMC Surgery 2013, 13:55 Page 5 of 5
... [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. ...
Full-text available
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. ...
Full-text available
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. ...
Full-text available
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.
... 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]. ...
Full-text available
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. ...
Full-text available
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.
... Many reports support this statement. 11,14 There is no disputing the surgical indication for symptoms of gastric outlet obstruction and torsion. ...
Full-text available
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.
Acute presentations of paraesophageal hernias such as strangulation, perforation, ulceration, and hemorrhage have been associated with increased morbidity and mortality. Such complications are indications for emergent surgical management, with earlier interventions shown to improve postoperative outcomes. However, surgical repair of complicated paraesophageal hernias remains technically challenging for many surgeons, and options for emergent management remain poorly described in the literature. Depending on clinical stability of the patient and surgeon expertise, surgical options may include use of minimally invasive techniques or life-saving damage control strategies to temporize patients until definitive repair.
Background: Gastropericardial fistula is a pathological communication between the stomach and the pericardium. This case report describes a gastropericardial fistula in a patient with upside-down stomach. Case presentation: The male patient (86) was examined for severe chest pain behind the sternum. CT revealed upside-down stomach with perforation on the lesser gastric curvature and fistulation into the pericardium with pneumopericardium. The patient was indicated for surgery. The procedure was performed from a transverse laparotomy and consisted of repositioning the stomach into the abdominal cavity, resection of the hernial sac, suture of the perforation of the lesser curvature, gastropexy and transhiatal drainage of the mediastinum and lesser sac. In the early postoperative period, the recovery was uneventful. Acute myocardial infarction with cardiorespiratory failure developed on the postoperative day (POD) 13. The patient died on POD 24 due to cardiorespiratory failure, confirmed by a sectional finding. Conclusions: Gastropericardial fistula is a rare acute complication of the diseases of the upper GIT. It is invariably a serious, life-threatening condition. Diagnosis is confirmed by thoracic CT and a contrast swallow study. The necessity of acute surgical treatment is widely accepted. The type of procedure must be selected based on the patient's individual criteria.
Die Magenperforation stellt trotz Fortschritt im Bereich der diagnostischen und operativen Möglichkeiten nach wie vor ein schweres Krankheitsbild mit relevanter Morbidität und Mortalität dar.
Full-text available
Gastro-oesophageal reflux disease (GORD) is a common gastrointestinal disorder with a genetic component. Our aim was to identify genetic factors associated with GORD. Four separate patient cohorts were analysed using a step-wise approach. (1) Whole genome linkage analysis was performed in 36 families. (2) Candidate genes were tested for GORD association in a trio cohort. (3) Genetic association was replicated in a case-control cohort. We also investigated genetic association to hiatus hernia (HH). (4) Protein expression was analysed in oesophageal biopsies. A region on chromosome 2, containing collagen type III alpha 1 (COL3A1), was identified (LOD = 3.3) in families with dominant transmission of GORD, stratified for hiatus hernia (HH). COL3A1 showed significant association with GORD in an independent paediatric trio cohort (p(corr) = 0.003). The association was male specific (p(corr) = 0.018). The COL3A1 association was replicated in an independent adult case control cohort (p(corr) = 0.022). Moreover, male specific association to HH (p(corr) = 0.019) was found for a SNP not associated to GORD. Collagen type III protein was more abundant in oesophageal biopsies from male patients with GORD (p = 0.03). COL3A1 is a disease-associated gene in both paediatric and adult GORD. Furthermore, we show that COL3A1 is genetically associated with HH in adult males. The GORD- and HH-associated alleles are different, indicating two separate mechanisms leading to disease. Our data provides new insight into GORD aetiology, identifying a connective tissue component and indicating a tissue remodelling mechanism in GORD. Our results implicate gender differences in the genetic risk for both for GORD and HH.
THE multiplicity of terms that have been used to describe herniation of the stomach alongside the esophagus and into the posterior mediastinum suggest the confusion which exists concerning both the pathophysiology and the management of this disorder. Up-side-down stomach, rolling hernia, intrathoracic stomach, parahiatal, and paraesophageal hernia are only a few of the terms applied to this problem. With few exceptions, this condition has not been separated in the literature from sliding hernia, and yet the sequelae and management of the two conditions are entirely different.In textbooks published as recently as 1958,1 illustrations of what are called parahiatal hernia show a component of the diaphragm between the herniated stomach and the esophagus, with a separate opening adjacent to the esophageal hiatus through which the stomach reportedly herniates. A substantial segment of the diaphragm lying between the herniated stomach pouch and esophagus is described, but the anatomical details of
HISTORY: A 77-year-old woman developed progressively increasing weakness, vertigo, dyspnoea, cardiac arrhythmias, left-sided chest pain, dyspepsia, dysphagia and weight loss. 11 years before admission she had a right mastectomy and 5 years later a left mastectomy, both for carcinoma. FINDINGS: She had an iron deficiency anaemia (haemoglobin 6.8 g/dl, ferritin level 9 mg/dl, mean corpuscular volume 64.3 fl). Neoplasm was excluded by extensive radiological and endoscopic examination, which however demonstrated upside-down stomach due to a large paraesophageal hernia. TREATMENT AND COURSE: Percutaneous gastroscopic gastrostomy was performed to reposition and fixate the stomach. Using two gastroscopes the stomach was replaced into the abdomen and fixed with three gastrostomies. The gastrostomy tubes were removed 15 days later. One year after the operation the patient was symptom-free and the stomach remained well fixed. A small residual hernia was still demonstrable radiologically. CONCLUSION: This case suggests that percutaneous endoscopic gastrostomy is a satisfactory procedure for the repair of an upside-down stomach.
: Upside-down stomach usually is asymptomatic in adults, but sometimes it can cause regurgitation, vomiting, and weight loss. This condition has an incidence increasing with age thus increasing the risk of surgical intervention. : A 90-year-old man was admitted with dysphagia, postprandial regurgitation, and an 18 kg weight loss in the past year. Gastroscopy revealed a significantly dilated, cranky esophagus and an upside-down stomach. The diagnosis was confirmed by a barium swallow and computed tomography. The stomach was repositioned with a gastroscope using insufflation and an α-loop maneuver under fluoroscopic guidance. A percutaneous endoscopic gastrostomy tube was then inserted to fix the stomach. The patient was discharged on the first postinterventional day. He gained 6 kg in the next 2 months. : High-risk patients with upside-down stomach can be managed by endoscopic repositioning of the stomach and percutaneous endoscopic gastrostomy fixation. This is a useful alternative therapeutic intervention. There have been 14 similar cases being reported in the literature.
The position of the gastroesophageal junction is maintained by a complex of fibroelastic ligaments. The purpose of this study was to characterize and compare the histology of these ligaments in patients with gastroesophageal reflux disease (GERD) and hiatal hernia (HH) versus GERD alone, with emphasis on the elastin morphology. Thirteen patients were examined at the time of laparoscopic fundoplication for symptomatic GERD; nine had no significant HH and four had large diaphragmatic hernias (GERD/HH). Tissue biopsies were obtained from the gastrohepatic ligament (GHL, n=5 and n=3, GERD and GERD/HH, respectively), the phrenoesophageal ligament (n=7 and n=4, respectively), and the gastrophrenic ligament (n=6 and n=4, respectively). Sections of fixed tissue were stained with hematoxylin and eosin, Masson's trichrome, and resorcin-fuchsin for analysis of elastic fibers by light microscopy, and elastin area was quantified and expressed as a percentage of the imaged tissue. Elastin and collagen fibers were prominent in all ligaments in patients with GERD alone. In patients with GERD/HH, there was fragmentation and distortion of elastin in the phrenoesophageal ligament and gastrohepatic ligament, and to a lesser degree, in the gastrophrenic ligament. Compared with patients with GERD alone, the presence of hiatal hernia was associated with a reduction in elastin area by more than 50% in the phrenoesophageal ligament ([mean +/- SEM] 31.0%+/-3.3% versus 15.1%+/-1.3%, p < 0.01) and gastrohepatic ligament (26.9% +/- 0.5% versus 12.5%+/-0.1%, p < 0.008). There was no decrease with respect to elastin in the gastrophrenic ligament. The periesophageal ligaments in patients with GERD are characterized by prominent elastic fibers. In contrast, GERD/HH is associated with depletion of elastic fibers in two of three ligaments supporting the gastroesophageal junction. Elastic fiber depletion in the periesophageal ligaments thereby provides a structural basis for the development of HH. It remains unclear if this represents a primary (etiologic) alteration or if it is a secondary phenomenon.
The pathophysiology of hiatal hernias is incompletely understood. This study systematically reviewed the literature of hiatal hernias to provide an evidence-based explanation of the pathogenetic theories and to identify any risk factors at the molecular and cellular levels. A systematic search of the Medline and Pubmed databases on the pathophysiology of hiatal hernias was performed to identify English-language citations from the database inception to December 2010. Although few studies have examined the relationship of molecular and cellular changes of the diaphragm to the pathogenesis of hiatal hernias, there appear to be three dominant pathogenic theories: (1) increased intraabdominal pressure forces the gastroesophageal junction (GEJ) into the thorax; (2) esophageal shortening due to fibrosis or excessive vagal nerve stimulation displaces the GEJ into the thorax; and (3) GEJ migrates into the chest secondary to a widening of the diaphragmatic hiatus in response to congenital or acquired molecular and cellular changes, such as the abnormalities of collagen type 3 alpha 1. The pathogenesis of hiatal hernias at the molecular and cellular levels is poorly described. To date, no single theory has proved to be the definitive explanation for hiatal hernia formation, and its pathogenesis appears to be multifactorial.
Treatment of type 4 hiatal hernia using a minimally invasive approach is challenging and requires good familiarity with this technique. From October 1992 to August 2010, 40 patients with a median age of 68 years underwent laparoscopic anterior hemifundoplication surgery for upside-down stomach and were included in our prospective study. The median symptoms duration was 5 years. The leading clinical symptoms were postprandial, epigastric, or retrosternal pain (80%), heartburn (78%), regurgitation (80%), dysphagia (53%), and anemia (48%). Preoperative evaluation included blood test, chest X-ray, upper endoscopy, and barium swallow. In some patients an esophageal 24-h pH study and esophageal manometry were performed. The median follow-up was 46 months using a standardized questionnaire, including Smiley score, modified Visick score, gastrointestinal quality-of-life index (GQLI), and specific reflux symptoms score. Surgery was finished laparoscopically in 39 patients (97%). One patient had to be converted to an open procedure because of severe adhesions. Mesh hiatoplasty had to be performed in one patient due to a large hiatal defect. Median operative time was 160 min (range=90-275) and median blood loss was 5 ml (range=0-300). Seven patients (18%) presented with acute symptoms. Intraoperative technical complications occurred in four patients (10%) and nontechnical complications in two cases (5%). Median postoperative hospital stay was 5 days (range=2-17). Postoperative complications occurred in two patients (5%): one pleural effusion and one surgical emphysema. There was no mortality or symptomatic recurrence. All scores showed significant improvement and patient satisfaction. Laparoscopic treatment of type 4 hiatal hernia is safe. With respect to the quality of life, anterior hemifundoplication is highly effective.
Ligamentous attachments maintain the normal anatomic position of the gastroesophageal (GE) junction. Failure of these elastic ligaments through an alteration in collagen synthesis, deposition, and metabolism may be a primary etiology of hiatal hernia formation. Differential expression of zinc-dependent matrix metalloproteinases (MMPs) is largely responsible for collagen remodeling. The purpose of this study was to survey baseline levels of MMPs in supporting ligaments of the GE junction from patients without hiatal hernia. Following an institutional review board-approved protocol, plasma and tissue biopsies of the gastrohepatic ligament (GHL), gastrophrenic ligament (GPL), and phrenoesophageal ligament (PEL) were obtained in six patients without a hiatal hernia during laparoscopic anterior esophageal myotomy for achalasia. Total protein extracts from tissue biopsies were analyzed for elastases MMP-2, -9, and -12 and collagenases MMP-1, -3, -7, -8, and -13 using a multiplex profiling kit (R&D Systems, Minneapolis, MN). Data are reported as mean +/- standard deviation. Statistical significance (p < 0.05) was determined using Tukey's test and analysis of variance. In control patients without hiatal hernias, increased levels of MMP-2 (p < 0.02) were detected in the GHL compared with the GPL and PEL, respectively. Tissue levels of MMP-1, -12, and -13 were not detectable. Gelatinase-A (MMP-2) is present in the GHL and plasma of control patients. The GHL may provide the primary GE junction supporting ligament to compare tissue from patients with type I (sliding) and type III (paraesophageal) hiatal hernias to examine the role of altered collagen metabolism in hiatal hernia formation.
Several studies have shown that laparoscopic hernia repair for large paraesophageal hiatal hernia is associated with a high recurrence rate. Therefore, some authors recommend the use of prosthetic meshes. Considering the dynamic area between the esophagus and the diaphragmatic crura with its constant motion, it is astonishing that only a minor number of surgeons describe mesh-associated complications. Between January 2000 and August 2008, 26 patients of the Centre Hospitalier Emile Mayrisch (CHEM, Luxembourg) underwent laparoscopic repair for large paraesophageal hiatal hernia (median age, 70 (range, 39-90) years). In nine patients, prosthetic mesh reinforcement was performed (7 composite/2 mono-phase mesh). Crural repair without tension was performed only with sutures. There were no conversions. Follow-up assessment was prospective with the GIQL (Gastro-Intestinal Quality of Life) Index. Responses to the GIQLI questionnaires were obtained from 20 patients (6 died of unrelated causes). Nineteen patients were satisfied with their symptom control 1 year after the operation (GIQLI 127). Sixteen patients had radiological follow-up (median, 24 months). Three patients treated without mesh (3/10) showed a radiological recurrence. All of them (3/10) had symptoms. None of the controlled patients with mesh (0/6) showed a recurrence. One patient developed a severe aortal bleeding 1, 2, and 3 weeks after the laparoscopic mono-phase mesh repair. During conventional operation, the bleeding stopped. Three years later, the follow-up showed a satisfied patient (GIQLI 127). In view of the described complication, there is still considerable controversy regarding the routine use of mesh. To increase safety, a composite mesh should be preferred.