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NewYork-Presbyterian Hospital Psychiatry
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Case of the Month - September 2017

This 90 year old male presented to the ED complaining of epigastric pain and coffee ground emesis.

Question 1 : What’s wrong with these pictures?

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Answer 1:

There is a large air-fluid level projecting over the lower chest most likely due to a hiatal hernia (arrows below).

Question 2: What’s the difference in a sliding and a paraesophageal hiatal hernia? Which has more concerning complications?
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Answer 2:

In a sliding hiatal hernia (which is by far the most common type), the entire GE junction and gastric cardia slide upwards whereas in a paraesophageal hernia, the GE junction maintains its position while the gastric fundus herniates upwards.

While both types of hernias typically cause only GERD symptoms, a paraesophageal hernia may also be complicated by obstruction, gastric volvulus and GI bleeding of the herniated fundus. The ED team ordered a CT scan due to clinical concern for obstruction which revealed an obstructed intrathoracic gastric volvulus. GI attempted to reduce it endoscopically but was unable to and the patient required surgical repair of the volvulus.

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