Massive Paraesophageal Hernia Mimicking Pulmonary Embolus

An 87-year-old woman presented with a traumatic fracture of her right femoral neck. After admission she became tachypneic, tachycardic, and had increased oxygen requirements. Computed tomography showed no pulmonary embolism, but revealed a 17 × 10-cm type-IV paraesophageal hernia (Figs. 1 and 2). The hernia included the entirety of her stomach, majority of the pancreas, portions of the duodenum, the splenic flexure of the colon, and associated vasculature. Fewer than 5% of paraesophageal hernias involve viscera beyond the stomach,¹ and pancreatic involvement is especially rare.^2,3 Her acute dyspnea was attributed to immobility, atelectasis, and the massive hernia. She ultimately had a right hip hemiarthroplasty with successful postoperative extubation. She was weaned off oxygen and was asymptomatic at discharge.

Figure 1.

Massive paraesophageal hernia—coronal view. Black arrow: pancreas. The pancreatic head is adjacent to the right diaphragm, and the associated pancreatic vasculature can be seen inferior to the pancreas. White arrow: stomach. The stomach is adjacent to the carina and left mainstem bronchus. White star: splenic flexure of the colon.

Figure 2.

Massive paraesophageal hernia—axial view. White arrow: pancreas. The majority of the pancreatic outline can be seen in this view.

Elective surgery of asymptomatic paraesophageal hernias was historically thought to be required to prevent the development of life-threatening complications.⁴ However, the mortality rate from elective laparoscopic repair is approximately 1.4%, while the lifetime risk of death from watchful waiting is estimated to be approximately 1%.⁴ The lifetime risk of developing acute symptoms requiring emergency surgery also decreases exponentially after 65 years of age.⁴ Thus, watchful waiting appears to be a reasonable strategy for some minimally symptomatic or asymptomatic paraesophageal hernias.