- Case Report
- Open Access
An unusual presentation of a patient with intrathoracic stomach: a case report
© licensee BioMed Central Ltd. 2009
Received: 10 August 2008
Accepted: 31 March 2009
Published: 9 June 2009
An intrathoracic stomach is the end stage of a hiatal hernial diaphragm and has a very low incidence. Frequently the diagnosis is made incidentally by endoscopic or radiographic investigations. There could be no clinical symptoms, however an intrathoracic stomach could be life treating. In this case we report a 61-year-old woman with an atypical presentation of an intrathoracic stomach. The patient had fever, night sweats and cough; the chest X-ray showed a retroperitoneal mass. A computed tomography scan was performed for determining the diagnosis of an intrathoracic stomach.
A hiatal hernia diaphragm is frequently found on radiographic or endoscopic investigations and usually needs no interventions. An intrathoracic stomach is the end stage of a hiatal hernia diaphragm and it is rarely found. An intrathoracic stomach could asymptomatic, although it could be associated with serious complications as incarceration, bleeding and perforation. Therefore a surgical intervention could be necessary. The purpose of this paper was to report a patient with an atypical presentation of an intrathoracic stomach.
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 . 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 . 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 . 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 . 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 .
Hiatal hernia diaphragms are commonly found, however an intrathoracic herniated stomach is rare. The diagnosis of an intrathoracic stomach should be considered in patients with a large mass on a chest X-ray. An intrathoracic stomach could be asymptomatic, however clinical symptoms could be life treating. If there are symptoms a surgical intervention is indicated.
Written informed consent was obtained from the patient for the publication of this case report and for the use of the accompanying image. A copy of the written consent is available for the Editor-in-Chief of this journal.
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