Life‐threatening complications of hiatus hernia

Sliding hiatus hernias are relatively common in the elderly population and the associated risk of aspiration is well recognised. We recently had a patient under our care who presented with two unusual and life-threatening complications of massive hiatus hernia. Both conditions have been reported previously, but are very rarely encountered by anaesthetists and intensivists. An 89-year-old woman was admitted to hospital for the elective resection of an adenocarcinoma of the caecum. She was well for her age, but was known to have a large, asymptomatic hiatus hernia. The surgical procedure and the first postoperative day were uneventful. On the second day, she complained of dyspnoea and discomfort within her chest. She was found to be hypotensive and was transferred to the Critical Care Area for resuscitation and further management. A pulmonary artery flotation catheter was inserted. Cardiac output studies revealed a low cardiac index (2.4 l.min−1.m−2) with a moderately raised pulmonary capillary wedge pressure (17 mmHg). A chest X-ray revealed a grossly distended stomach and loops of bowel within the thoracic cavity. Transthoracic echocardiography was technically limited but revealed normal contractility and valvular function. We thus presumed that cardiac output was limited by left atrial compression by the massively dilated intrathoracic stomach. Attempts to relieve the distension of the stomach by means of a large-bore nasogastric tube were unfortunately not successful. The patient's condition deteriorated inexorably. Surgical intervention was not undertaken because of the patient's age and rapid deterioration. She died 14 h after her admission to Critical Care in spite of ventilatory and inotropic support. Post-mortem findings revealed an unusual cause of death. The entire stomach had passed into the thoracic cavity and had subsequently undergone organoaxial torsion. This had led to venous infarction of the stomach. The patient's heart was morphologically normal, confirming our suspicions that external compression had been the cause of the low cardiac output. Torsion of the intrathoracic stomach occurs because of the peritoneal tethering of the duodenum and the oesophageal–gastric junction. The body and greater curvature lie free and undergo torsion around the long axis of the stomach [1]. Haemodynamic compromise secondary to left atrial compression is also a rare but recognised complication of massive hiatus hernias [2]. Such patients may present with clinical features of left ventricular failure. A marked reduction in pulmonary capillary wedge pressure and subsequent improvement in cardiac output has been noted with the successful decompression of the stomach [3]. However, nasogastric decompression is not possible once the organ has undergone torsion. We would recommend that any patient with a large hiatus hernia should have a nasogastric tube in place until gastro-intestinal function has recovered. Should such a patient develop haemodynamic compromise in the early postoperative period, left atrial compression should be excluded.