Sailaja Pisipati, MD, FRCS1, Mohamed Taha, MD1, Tomas Hinojosa, MD2, Omar Canaday, MD1
1University of Nevada Reno School of Medicine, Reno, NV; 2VA Sierra Nevada Health Care System, Reno, NV
Introduction: While sliding hernias (type I) constitute 90%-95% of hiatus hernias (HH), paraesophageal hernias (PEHs) (type II-IV) account for the remaining 5%-10%. PEHs have become increasingly common with age and obesity being the contributory factors. They can either be symptomatic or asymptomatic. We report a case of large PEH presenting with symptoms masquerading as new-onset heart failure.
Case Description/Methods: A 71-year-old healthy gentleman with no known prior cardiac history was evaluated in urgent care for progressively worsening exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, bilateral lower extremity edema, weight gain and dizziness for two months. Review of systems was negative except for recent intake of NSAIDs. Past history was significant for a small HH and chronic gastritis, sigmoid diverticulosis and hemorrhoids on endoscopic evaluation ten years prior. He was hemodynamically stable. Examination revealed pitting edema of lower extremities and S3 gallop. Patient was commenced on oral furosemide; urgent lab work, chest x-ray and echo were requested. He was advised to be admitted for blood transfusion and in-patient evaluation of anemia when his hemoglobin returned at 5.5 g/dl. Evaluation by gastroenterology suggested that patient had early satiety for few months. Urgent upper endoscopy revealed several Cameron lesions possibly accounting for chronic blood loss anemia. Barium upper series demonstrated an intrathoracic gastroesophageal junction (GEJ) and a large PEH with organoaxial gastric volvulus and no signs of obstruction. CT thorax confirmed a type III PEH. There was no evidence of primary cardiopulmonary pathology on echo and thoracic CT. Laparoscopic repair of large HH and Nissen’s fundoplication were performed following which symptoms and anemia resolved.
Discussion: Large PEH can be an incidental finding on endoscopic or radiological evaluation for unrelated reasons. Despite this, most patients have had symptoms attributed to other causes. Common symptoms include heartburn, regurgitation, dysphagia, early satiety, chest pain, dyspnea. Microcytic anemia was reported in 17%-47% of cases; this was attributed to chronic blood loss from Cameron lesions which are gastric mucosal erosions from crural pressure at the neck of HH. Our patient likely had high-output cardiac failure due to profound anemia in the setting of Cameron’s lesions from a large PEH. Other common causes of chest symptoms and anemia should be excluded before attributing these symptoms to a large PEH.
Citation: Sailaja Pisipati, MD, FRCS; Mohamed Taha, MD; Tomas Hinojosa, MD; Omar Canaday, MD. P0453 - CHF - CHRONIC HERNIAL FAILURE PRESENTING AS CONGESTIVE HEART FAILURE. Program No. P0453. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.