Air–Fluid Level in the Right Hemithorax: A Case Hard to Stomach

Question: A 55-year-old man with known gastroesophageal reflux disease presented to his primary care physician with nausea and dry heaving on a near daily basis. He had no abdominal pain, dysphagia, or respiratory distress. The physical exam and laboratory workup were otherwise unremarkable. A chest radiograph (Figure A) revealed an air–fluid level above the right diaphragm. Enhanced computed tomography was also abnormal. What is the diagnosis and how should it be managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. A computed tomography scan of the abdomen with intravenous contrast (Figure B) and endoscopy confirmed an exceptionally large hiatal hernia with total gastric displacement, in which the stomach was situated above the diaphragm and projected into the posterior mediastinum. The diaphragmatic hiatus had a large hernial gap of dimension 4.2 × 5.6 cm. At the last follow-up, the patient was advised to eat small portions, and given the severity of his symptoms, a surgical intervention was recommended. He is scheduled for a laparoscopic hernia repair with partial wrap and adjunct gastropexy. The pathophysiology of a hiatal hernia involves an opening in the diaphragm that allows for the intra-abdominal organs to protrude into the thoracic cavity. And although hiatal hernias are not uncommon, an intrathoracic stomach is the end stage of a hiatal hernia and is rarely found.1Bilgin Y.M. van der Wiel H.E. An unusual presentation of a patient with intrathoracic stomach: a case report.Cases J. 2009; 2: 7514Crossref PubMed Scopus (3) Google Scholar With large hernias, early repair is recommended to avoid further risks, such as gastric volvulus, ischemia, bleeding, or perforation.2Leeder P.C. Smith G. Dehn T.C. Laparoscopic management of large paraesophageal hiatal hernia.Surg Endosc. 2003; 17: 1372-1375Crossref PubMed Scopus (68) Google Scholar If such complications arise, emergent repair is required. However, in cases such as ours, elective repair can be performed. Laparoscopic repair has become the mainstay of treatment and is superior to open repair.3Castelijns P.S. Ponten J.E. Bouvy N.D. et al.Intrathoracic stomach in hiatal hernia: the role of laparoscopic repair.Minerva Chir. 2018; 73: 64-76PubMed Google Scholar