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HIDDEN IN PLAIN SIGHT: A CASE OF HIATAL HERNIA CAUSING RECURRENT PANCREATITIS
Jason Nguyen
*, Kevin Gopala Rao, Carmen Tormo Carrillo, Priya Mohan, Mohammed Akram, Werner Andrade-Ortiz, Bernardo Reyes
Internal Medicine, HCA Florida Aventura Hospital and Medical Center, Aventura, FL
Introduction: Hiatal hernia is the translocation of the stomach or abdominal contents into the thoracic cavity through the esophageal hiatus. Usually, hiatal hernias either cause mild symptoms of gastroesophageal reflux or are asymptomatic, but there are rare cases where serious complications can arise, usually with Type IV paraesophageal hernias, which typically involve the stomach, but could include the small bowel, colon, or spleen. The pancreas is usually not involved due to being anchored to the retroperitoneum by the ligament of Treitz, but even when it is, acute pancreatitis is an uncommon complication. We present a case of an 86-year-old female who presented with recurrent pancreatitis and found to have a large hiatal hernia containing the pancreas causing recurrent pancreatitis.
Case Description: An 86-year-old female with past medical history significant for prior episode of pancreatitis, hypertension, and hyperlipidemia presented for sharp midepigastric pain radiating to the back. She denied and alcohol use or history of abdominal surgeries. Laboratory studies were grossly unremarkable, including normal liver enzymes, triglyceride levels, and IgG4, however her lipase was 2,524. Computed tomography of the abdomen and pelvis showed a large hiatal hernia including a distended stomach. The pancreas could not be visualized. Abdominal magnetic resonance imaging was performed after resolution of the acute episode of pancreatitis, which revealed the pancreas within the hiatal hernia in the thoracic cavity. She underwent elective paraesophageal hernia repair with mesh implantation, Toupet fundoplication, and gastropexy.
Discussion: With this patient, the most common etiologies of pancreatitis were ruled out before establishing the mechanical manipulation of the pancreas in the hiatal hernia as the underlying cause of her recurrent pancreatitis. Although she remained mostly asymptomatic, the recurring episodes of pancreatitis warranted evaluation for prevention with surgical intervention. Usually, surgical intervention is reserved for younger populations, due to lower morbidity and better outcomes, however there is no difference in mortality between young or geriatric populations and quality of life was improved significantly in both populations.
Conclusion: Hiatal hernia is a frequently seen diagnosis that is either asymptomatic or with mild symptoms. Involvement of the pancreas with a hiatal hernia is extremely rare and usually does not cause acute pancreatitis as a complication. Surgical repair should be considered on a case-by-case basis, as younger patients have lower rates of morbidity, but all age groups have similar mortality and surgical repair significantly improves quality of life.
Figure 1. Abdominal magnetic resonance imaging showing the pancreas within the thoracic cavity in the hiatal hernia sac.
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