Gastric torsion associated with a type IV hiatal hernia in two cats

Abstract

Case series summary

A 5-year-old intact female domestic shorthair and a 4-year-old spayed female domestic shorthair were presented for dyspnoea and unproductive vomiting. Thoracic radiographs were suggestive of either diaphragmatic hernia or hiatal hernia. Surgical treatment consisting of reduction and repositioning of the stomach and incisional gastropexy was performed (bilateral in the first case, one-sided in the second case). The second cat died a few hours postoperatively, whereas the other cat was still alive 7 months postoperatively.

Relevance and novel information

This case series describes surgical management of type IV hiatal hernia with gastric volvulus in two cats, which is a rare condition in cats. The radiographic challenge presented by this rare presentation is discussed. These cases demonstrate that bilateral gastropexies may be considered in type IV hiatal hernia in cats; however, further research about the aetiology and optimal treatment is necessary.

Introduction

Gastric dilatation-volvulus (GDV) or gastric torsion associated with dilatation is a well-known syndrome in dogs.^{1 –3} A similar clinical presentation has been described in cats, although it is less frequently reported and documented to be spontaneous or associated with traumatic diaphragmatic hernia. ⁴ In a larger literature review, ⁵ diaphragmatic hernia appeared to be a predisposing factor in the development of this disease. According to these studies, feline GDV is a surgical emergency, as it is in dogs and humans.^1,6

Hiatal hernias refer to conditions in which organs of the abdominal cavity, most commonly the stomach, herniate through the oesophageal hiatus into the medias-tinum (left-sided hernia) ⁷ or into the Sussdorf’s space (right-sided hernia). ⁸ Four types of hiatal hernias are recognised: type I (sliding hernia); type II (paraesophageal hernia); type III includes the elements of both types I and II hernias; and type IV hiatal hernias involve herniation of the stomach and other abdominal organs into the thoracic cavity. ⁷ Type IV hiatal hernia is a rare condition in cats, which in a recent study represented only 7.2% of cases. ⁹

This case series describes gastric torsion in two cats, not associated with diaphragmatic hernia but with hiatal hernia. The aim was to add to the paucity of information on feline gastric torsion by describing two additional cases with follow-up.

Case series description

Case 1

A 5-year-old intact female domestic shorthair was presented for a 24-h history of dyspnoea, unproductive vomiting, anorexia and lethargy. Before admission, the referring veterinarian had been consulted and thoracic radiographs showed evidence of a left dorsal diaphragmatic hernia with gastric displacement (Figure 1).

Figure 1.

Case 1: thoracic radiographs at admission. (a,b) The stomach is severely distended with gas and displaced craniodorsally in the thoracic cavity (black arrowheads). It has a central position, mildly lateralised on the left side and is in contact with the cardiac silhouette. The pulmonary volume is severely reduced. No stomach is visible in the abdomen. (a) Liver lobes are visible in the ventral part of the abdomen on the right lateral view and are mildly enlarged (white arrowheads). (b) On the ventrodorsal view, the left liver lobes are not clearly identified (black circle). A soft tissue density surrounds the stomach (black arrows). The serosal details are moderately reduced in the ventral part of the abdomen, which is compatible with peritoneal effusion and/or steatitis, among other causes. The radiographs are consistent with a gastrothorax secondary to dorsal diaphragmatic hernia or hiatal hernia with possible left-sided liver herniation

Clinical examination at admission revealed open-mouth respiratory distress, expiratory dyspnoea and abdominal pain. Emergency stabilisation consisted of oxygen therapy and sedation (butorphanol 0.4 mg/kg IV). The results of abdominal and thoracic point-of-care ultrasound (POCUS) examination revealed a dilated stomach cranial to the liver within the thoracic cavity, and a small volume of pleural effusion, suggestive of diaphragmatic hernia. A nasogastric tube was placed to evacuate the air contained in the stomach and antiemetic therapy was administered (maropitant 1 mg/kg IV).

Despite decompression of the stomach, the respiratory distress worsened (increased expiratory effort and persistence of open-mouth breathing), prompting emergency surgery. After administration of methadone (0.2 mg/kg IV), midazolam (0.2 mg/kg) and propofol (2 mg/kg), the cat was intubated, and anaesthesia was maintained with isoflurane. Antibiotic prophylaxis was provided with ampicillin–sulbactam (20 mg/kg IV) and fluid therapy with isotonic crystalloid solution (lactated Ringer’s solution, 3 ml/kg/h) was initiated. The cat was placed in dorsal recumbency, followed by routine surgical preparation.

A xiphopubic laparotomy was performed and a type IV hiatal hernia with herniation of the stomach, duodenum, right lobe of the pancreas, left lateral lobe of the liver and spleen was evidenced (Figure 2). After reduction of the herniated organs, an area of flaccid muscle measuring 3 cm in diameter, creating a depression in the left dorsal region of the diaphragm, was observed. The diaphragm was intact. There was evidence of caudocranial torsion of the stomach with omental incarceration (Figure 3). The omental tear was enlarged by hand to avoid recurrence of incarceration. The stomach was repositioned and right and left incisional gastropexies caudal to the 13th rib were performed, using a polydioxanone 2 metric monofilament suture (polydioxanone suture II). No other abnormalities were found. Peritoneal lavage and routine closure were performed.

Figure 2.

Case 1: intraoperative photograph of the type IV hiatal hernia, involving the stomach (white arrow), duodenum, right lobe of the pancreas, left lateral liver lobe and spleen. The hiatal hiatus appears enlarged

Figure 3.

Case 1: intraoperative photograph of the omental tear. A shredding along the white arrow was performed to avoid the risk of recurrence of strangulation

The cat’s clinical condition improved postoperatively and her respiratory rate normalised. The patient started eating and there was no vomiting; therefore, she was discharged 3 days postoperatively. Treatments prescribed at discharge were antiemetic therapy (maropitant 2 mg/kg PO q24h for 2 days) and analgesia (meloxicam 0.05 mg/kg PO q24h for 10 days).

At 6 months postoperatively, the cat underwent exploratory laparotomy by the referring veterinarian after signs of stomach dilatation (respiratory distress and vomiting). Gastropexies were removed during that surgery because there were suspected to be adhesions.

Two weeks after this second surgery, a recurrence of gastric dilatation through the hiatal hernia was suspected. The cat was presented at the hospital with respiratory distress and vomiting. After emergency stabilisation, a third surgery was performed, consisting of a herniorrhaphy with simple suture and a left incisional gastropexy.

One month after the third surgery, a telephonic follow-up was performed. The owner reported no more digestive signs or respiratory distress.

Case 2

A 4-year-old spayed female domestic shorthair was presented for severe lethargy and abdominal pain. One month before admission, the owners consulted another veterinarian for similar signs associated with a 48-h history of unproductive vomiting. Severe abdominal distension and a soft tissue density caudal to the heart had been visualised on radiographs. An exploratory laparotomy with gastrotomy was performed. No foreign body was found. At discharge, antibiotics (amoxicillin–clavulanate and marbofloxacin) and corticosteroids were prescribed.

On admission, the cat was lethargic, and clinical examination revealed severe hypotension (mean arterial blood pressure 50 mmHg), hypothermia (35.6°C), paradoxical abdominal motion and heart murmur. Thoracic POCUS showed the abdominal organs (liver and stomach) within the thoracic cavity. Thoracic radiographs at admission confirmed the position of the stomach and liver within the thoracic cavity, with a severe gastric dilation. Radiographs were consistent with diaphragmatic or hiatal hernia (Figure 4). The right-sided position of the stomach and the suspected gastric compartmentalisation were consistent with concomitant gastric torsion.

Figure 4.

Case 2: (a) the stomach has a cranial position and is located cranially to the diaphragm on the right side of the thoracic cavity (black arrowheads). The stomach is in contact with the cardiac silhouette, which is displaced towards the left (black arrow). The pulmonary volume was reduced, and pleural effusion was present. No stomach is visualised in the peritoneal cavity. (b) Thoracic radiographs at admission show severe gastric distension with gas and suspicion of gastric compartmentalisation (dotted lines). A part of the liver is visible in the cranioventral aspect of the abdomen and has rounded borders (white arrowheads in b, c). (c) An oesophageal tube was inserted into the oesophagus (white arrows) and confirmed the thoracic location of the stomach. Multiple soft tissue opaque structures are partially superimposed on the distended stomach (black star). The serosal details are reduced, which was compatible with peritoneal effusion and/or steatitis. The radiographs were consistent with a gastrothorax secondary to dorsal diaphragmatic hernia or hiatal hernia. The right-sided position of the stomach and the suspected gastric compartmentalisation could be consistent with concomitant gastric dilatation-volvulus

Emergency stabilisation was similar to case 1 (supplemental oxygen therapy and analgesia), and a nasogastric tube was placed to decompress the stomach, allowing the withdrawal of 100 ml of air (Figure 4b).

Despite initial stabilisation, respiratory distress worsened (increased respiratory rate and effort), motivating emergency surgery. Anaesthesia and surgical prepar-ation were similar to case 1.

A xiphoumbilical laparotomy was performed to explore the entire abdominal cavity. The stomach and the omentum were not visualised. A type IV right hiatal hernia with incarceration of the stomach, spleen and omentum magnum through the oesophageal hiatus was diagnosed. A diaphragmotomy and caudal sternotomy were performed (Figure 5). Herniated organs were reduced without difficulty. Upon reduction, the stomach appeared twisted on its longitudinal axis, severely dilated and moderately cyanotic (Figure 6). A thoracic chest tube was placed and reconstruction of the oesophageal hiatus, left oesophagopexy and gastropexy were performed. The lungs were severely atelectatic. The sternum and the diaphragm were reconstructed while drainage of the intrapleural air was achieved via a chest tube. Peritoneal lavage and a routine abdominal closure were performed.

Figure 5.

Case 2: intraoperative photographs of the diaphragmotomy and caudal sternotomy. Involvement of dilated and rotated stomach (blue arrow), spleen and omentum magnum through the type IV hiatal hernia (white arrow)

Figure 6.

Case 2: intraroperative photographs of the gastric dilatation and volvulus, after being reintroduced into the abdominal cavity and before being repositioned

Postoperatively, the cat had a poor recovery from anaesthesia with severe hypothermia, and oxygen saturation in the range of 83–90%, which eventually returned to normal values within 3 hours postoperatively. Venous blood gas analyses, blood pH and lactate concentration were within physiological values. However, 8 h post-operatively, the cat died of a cardiorespiratory arrest despite attempts to conduct cardiopulmonary resuscitation.

Discussion

This is the first case series reporting type IV hiatal hernia and gastric torsion in cats with attempted surgical treatment. Type IV feline hiatal hernia is a rare condition, representing only 7.2% of cases compared with 85.7% of type I hiatal hernia in a recent case series. ⁹

The aetiology of hiatal hernias in dogs and cats is multifactorial and includes anatomical abnormalities. ¹⁰ In case 1, the left crus of the diaphragm appeared grossly abnormal, possibly secondary to a rupture or elongation, which could have led to the flaccid appearance of the diaphragm. A traumatic cause was unlikely, as the diaphragm would also have looked scarred or damaged, which was not the case. A congenital or neurodegenerative aetiology (affecting the left phrenic nerve) was also considered because the diaphragm was intact and no trauma was reported. In case 2, the aetiology remains unknown.

A rare consequence of type IV hiatal hernia is gastric volvulus. Cases of gastric volvulus combined with hiatal hernia have been described in humans^{6,11 –14} and in one dog. ¹⁵ According to a literature search in PubMed in January 2025, there are no previous reported cases of gastric torsion associated with hiatal hernia in cats.

Confirmation of gastric torsion with diagnostic im-aging can be difficult in cats because gastric dilatation without clear evidence of volvulus is the most common radiographic finding described on radiographs.^4,5 In this case series, severe gastric distension was noted, the stomach was located on the right side and compartmentalisation was suspected in one cat. The diagnosis was made more difficult because of the atypical intrathoracic gastric localisation, which was only confirmed after placement of a nasogastric tube (Figure 4). At this stage, an additional ventrodorsal view could have facilitated the diagnosis; however, obtaining several views can be hard to achieve in a critically ill cat. Because of the oesophageal hiatus left localisation, it may be challenging to differentiate between a type IV hiatal hernia and a dorsal and left-sided diaphragmatic rupture based only on a radiographic examination. ⁸

Oesophagogram could aid in the detection of hiatal hernia along with iatrogenic elevation of abdominal pressure. Displacement and narrowing of the caudal oesophagus by the cardia and fundus can be seen with type IV hiatal hernias. ⁸ However, barium aspiration is a potential complication of performing contrast studies. Therefore, an oesophagram should not be performed in unstable patients such as cats with GDV-associated hiatal hernia. A CT scan can also be performed to diagnose and grade hiatal hernia without the aspiration pneumonia risk and with higher resolution. ¹⁶ Nevertheless, a CT scan entails general anaesthesia – as sedation would not be appropriate in the context of a suspected hiatal hernia – and should be reserved for more stable or chronic cases owing to the anaesthetic risk.

In human medicine, after reduction and repositioning of the stomach, the most common techniques used are fundoplication and gastropexy.^{6,11 –14} One case was described in dogs with a type II hiatal hernia and managed with an emergency exploratory coeliotomy, during which the stomach was derotated and an incisional gastropexy, herniorrhaphy and splenectomy were performed. ¹⁵ Surgical management of gastric volvulus associated with hiatal hernia in the cat has not been previously described. In this case series, both cats underwent hiatus reconstruction (after revision surgery for case 1) and gastropexy. After diaphragm closure, the stomach was in its physiological position and a left incisional gastropexy was considered sufficient to avoid another volvulus. In case 1, left and right gastropexies were performed in the first place due to the residual flaccidity of the diaphragm that created a larger space for the cranial abdominal organs to move. With a single gastropexy, craniocaudal movements were still possible and could increase the risk of spleen and liver torsions.

Conclusions

Feline hiatal hernia remains a rare condition, and the concomitant presence of GDV is even more uncommon. The radiographic appearance of hiatal hernia associated with GDV might reveal the presence of gastric dilatation within the thoracic cavity, but evidence of volvulus is not always present. Cats with hiatal hernia should be surgically treated as soon as possible by repositioning herniated organs. Prophylactic gastropexy is recommended. Larger scale studies or reports would be helpful to characterise radiographic findings and the optimal management of hiatal hernia and gastric torsion in cats.