Sigmoid volvulus strangulation caused by a giant type IV hiatal hernia

A type IV hiatal hernia, characterized by the intrathoracic migration of abdominal viscera other than the stomach, is an uncommon and severe presentation of hiatal hernia. The resulting increase in intrathoracic pressure can cause a wide variety of symptoms on presentation and possibly lead to misdiagnosis. The colon, most often the transverse segment, is one of the organs that can be involved, leading to potentially life-threatening complications like volvulus, incarceration and strangulation. Of these, the strangulation of a synchronous sigmoid volvulus is extremely rare and requires prompt intervention. We report herein a 90-year-old woman who presented to the emergency department with a multitude of gastrointestinal and respiratory acute-onset symptoms. Imaging revealed a rare type IV hiatal hernia containing the entire stomach and the apex of a sigmoid volvulus. An emergency laparotomy was performed, in which the sigmoid volvulus was identified as partially incarcerated and strangulated within the giant paraesophageal hernia. The patient underwent a life-saving sigmoid colon resection and anterior gastropexy. To our knowledge, this is the first report of such a rare association between these two life-threatening and usually separated entities-a sigmoid volvulus strangulated within a giant type IV hiatal hernia. Recognizing the several possible scenarios of clinical presentation in complex type IV hiatal hernias is extremely important as early detection and immediate treatment are essential in reducing morbidity and mortality associated with this challenging condition. Computed tomography of the chest and abdomen is considered the gold standard in the diagnosis of both entities.