Left Atrial Compression by Hiatal Hernia in a Patient With Intestinal Occlusion

Abstract Introduction A 93–year–old woman was admitted to the emergency department due to undifferentiated shock, she was unconscious and hypotensive. A 12–leads EKG was unremarkable except for sinus tachycardia. The patient was reanimated using volume filling. The objective examination showed cold and sweaty skin, the thoracic auscultation was normal and the abdomen was bloated without tenderness. The cardiologist consultant was called to perform a complete echocardiography Investigation Following volemic filling, the patient became conscious. She reported to have difficulty evacuating for the past three days. The echocardiogram evidenced:” Left ventricle of small dimension hyperkinetic. Left atrium was very small and compressed by a massive external mass. Due to a displacement of mitral leaflet and severe hypovolemia, there was systolic anterior movement of anterior mitral leaflet with moderate mitral regurgitation and significant aortic gradient“. Considering the possibility that the mediastinal mass was the dilated gastric fundus of a hiatal hernia, we placed a nasogastric tube with aspiration of fecal material. After stabilizing, we took the patient for a complete total body CT scan, which confirmed the picture of intestinal obstruction with the presence of a massive hiatal hernia in the mediastinum. Management After volume refilling and aspiration of the gastric contents using a nasogastric tube, the patient reported a significant clinical improvement. The patient underwent intestinal resection and repair of the crural hernia. The patient was discharged home and a control echocardiogram showed good biventricular kinetics without significant valvular disease. Discussion A hiatal hernia is a condition in which the upper part of the stomach or other internal organ bulges through the hiatus of the diaphragm often causing gastroesophageal reflux disease. In our clinical case the hiatal hernia modified the clinical expression of the intestinal occlusion, i.e. not only a hypovolemic shock but the dilation of the gastric fundus present in the mediastinum determined the compression of the atrium with consequent reduction in cardiac output. The timely identification of these causes via echocardiogram allowed correct treatment. Conclusion We present a clinical case of initial undifferentiated shock where the use of echocardiography helped to understand a rare mechanism of shock: hypovolemia plus cardiogenic shock due to left atrial compression by a massive hiatal hernia.