An intrathoracic stomach results from a hiatal hernia in which an important portion of the stomach had herniated through the diaphragm into the chest. The esopahgeal hiatal hernias are divided into 4 types [1, 2]. The sliding hernia is the most commonly found type of esophageal hernia (represents 95% of all hiatal hernias) and is characterized by intrathroracic displacement of the gastro-esophageal junction (Type 1). Type 2 is the rolling or paraesophageal hernia, it shows displacement of the stomach fundus and anterior wall. Type 3 is a combination of types 1 and 2; the gastro-esophageal junction is displaced into the chest. Total herniation of the stomach represents the end stage of hiatal herniation and other organs could be herniated also to the chest (Type 4). The incidence of type 4 hiatal hernia compromises 0.3% of all hiatal hernias.
Most common clinical symptoms of an intrathoracic stomach are reflux and dysphagia. Due to food and air distension, patients with an intrathoracic stomach could present with postprandial pain, which can mimic angina and even myocardial infarction [3]. If the herniation is large compression of the lung may be the first symptom, which could lead to respiratory complications. Incarceration and strangulation of the intrathoracic stomach is a serious complication and could rarely lead to tension gastro-thorax [4]. Iron deficiency anemia could also be a presenting clinical symptom of an intrathoracic stomach. Anemia could be the result of mechanical irritation of the stomach leading to gastric erosions and ulcerations causing occult blood loss. Hematological and gastro-intestinal evaluations for other causes of blood loss are needed if iron deficiency anemia is present in patients with an intrathoracic stomach [5]. Our patient had no signs of blood loss in the laboratory investigations; therefore no further evaluations were performed. There is no indication for endoscopic investigation for the diagnosis of a hiatal hernia diaphragm. Most hiatal hernias are found incidentally on endoscopic or radiographic investigations. A fluid level on a chest X-ray suggests the presence of a hiatal hernia [1]. In our patient the presence of clinical symptoms with fever, cough, night sweats and weight loss and the absence of typical symptoms for an intrathoracic stomach had misled us. The differential diagnosis included mediastinal tumor, lymphoma or thymoma, however a computed tomography scan showed the final diagnosis of an intrathoracic stomach.
An asymptomatic intrathoracic stomach should be followed up. The treatment of a patient with a symptomatic intrathoracic stomach is a surgical intervention. Nowadays surgical repair is possible with laparoscopic techniques [6].