220 JCC, Vol. 42, No 3, juin 1999

Although the onset of inguinaland femoral hernias is oftenattributed to excessive physi-

cal strain,1 the development of a largehiatus hernia is rarely attributed tosuch exertion. Hiatus hernia can beprogressive and is often associatedwith advanced age, obesity or preg-nancy.2 It may present as an incidentalfinding in an asymptomatic patient orbe associated with a broad range ofsymptoms.1,2 Such symptoms can ex-tend from minimal gastrointestinalupset that is well tolerated to those in-volving obstruction, strangulation,perforation and hemorrhage.3,4 Themost severe symptoms are usually as-sociated with incarceration and re-quire surgical management.4 We re-

port a case of massive hiatal herniawith incarceration of antrum, pylorus,first part of the duodenum and trans-verse colon, resulting in obstructionof both the gastric outlet and thecolon. The onset of symptoms was re-lated to a single event of heavy physi-cal exertion while weightlifting.

CASE REPORT

A 30-year-old man complained ofinability to retain any oral feeding ex-cept clear fluids, no bowel movementexcept for occasional small amounts offlatus and mucus, and a 12-kg weightloss over a 30-day period. A commit-ted weightlifter, training 3 to 4 days aweek for approximately 3 years, he re-

lated the onset of his symptoms to asuccessful attempt to bench press 150kg. While doing so, he felt a sudden“tearing” pain in his upper abdomenand chest. By the following morningthe initial severe pain had abated con-siderably so that he was able to con-tinue his normal employment as a me-chanic. He had continued discomfortin his epigastrium and chest and anyattempt to take solid food resulted invomiting. The symptoms persisted for30 days, and he existed only on clearfluids during that time. He soughtmedical help after 30 days. He deniedany symptoms of gastroesophageal re-flux or hiatus hernia before this event,and the rest of his medical history wasunremarkable. On physical examina-

Case ReportÉtude de cas

SIMULTANEOUS PYLORIC AND COLONIC OBSTRUCTIONASSOCIATED WITH HIATUS HERNIA IN A WEIGHTLIFTER: A CASE REPORT

Patrick Casey, MD; M. Thomas Casey, MD

From the Department of Surgery, Dalhousie University, Halifax, NS

Accepted for publication Nov. 25, 1997.

Correspondence to: Dr. Patrick Casey, 6070 Inglis St., Halifax NS B3H 1L3; mtcasey@is.dal.ca

© 1999 Canadian Medical Association (text and abstract/résumé)

Hiatus hernia is usually attributed to conditions that cause a chronic increase in intra-abdominal pressuresuch as multiple pregnancies and obesity. A 30-year-old man, a weightlifter, had a massive hiatus herniacausing both high and low gastrointestinal obstruction but no involvement of the gastroesophageal junc-tion or fundus. The onset of the obstruction is attributed to an extreme increase in intra-abdominal pres-sure caused by the action of lifting weights.

On attribue habituellement une hernie hiatale à des conditions qui causent une élévation chronique de lapression intra-abdominale comme de multiples grossesses et l’obésité. Un homme de 30 ans, culturiste, aeu une hernie hiatale massive qui a causé une occlusion gastro-intestinale haute et basse sans toucher lajonction éso-gastrique ou le fundus. L’apparition de l’occlusion est attribuée à une élévation extrême de lapression intra-abdominale causée par le lever de poids.

tion he was 172 cm tall and weighed82 kg. The remainder of the examina-tion was unremarkable.A nasogastric tube was easily inserted

into the stomach and a small amount ofgastric contents was aspirated.

A barium swallow examinationshowed free flow into the stomach(Fig. 1), which contained a moderateamount of food residue. The gastro -esophageal junction and fundus werein their normal positions in the ab-domen. No contrast medium was seenin the antrum, pylorus or duodenumalthough the outline of the antrumappeared to be above the diaphragm.The following day, repeat films of theabdomen and chest (Fig. 2) showed amoderate amount of contrast mediumstill present in the stomach and clearlyoutlined a loop of transverse colon,containing contrast medium abovethe diaphragm. These findings wereinterpreted as indicating gastric outletobstruction and colonic obstructiondue to incarceration of the these viscerathrough a defect in the diaphragm.At laparotomy through a midline

upper abdominal incision, the distalhalf of the stomach, pylorus, and first

part of the duodenum were found tobe incarcerated through the esophagealhiatus alongside the loop of transversecolon. The gastro esophageal junctionwas within the abdomen and the fun-dus of the stomach was in its normalposition below the left leaf of the di-aphragm. This configuration fits thecriteria for the diagnosis of gastricvolvulus of the mesenteroaxial type.5

The displaced viscera were reducedinto the abdomen and the duodenumwas found to be abnormally mobilewith a short mesentery down to its sec-ond part. In spite of the prolonged in-carceration, there was no evidence ofvascular compromise. The enlargedhiatus readily admitted the surgeon’s 2fists into the retrocardiac space.The remnants of a markedly atten-

uated hernial sac were removed and,with a no. 56 Maloney bougie left inplace, the margins of the esophagealhiatus were approximated posterior to

PYLORIC AND COLONIC OBSTRUCTION WITH HIATUS HERNIA

CJS, Vol. 42, No. 3, June 1999 221

FIG. 1. Admission contrast radiograph.

FIG. 2. Posteroanterior (left) and lateral (right) radiographs obtained on day 2 of the patient’s admission, demonstrating colon in the chest.

the esophagus to reduce the hiatus toits normal size. Because of the exten-sive derangement of the supportingstructures, including no identifiablephrenoesophageal ligament, Nissenfundoplication was performed.The patient’s postoperative course

was uncomplicated except for profusediarrhea for several days. He was dis-charged from hospital 1 week after therepair at which time he was eating afull regular diet and was having nor-mal bowel movements. At the 1-month follow-up he had no symptomsand was continuing to gain weight.

DISCUSSION

Four types of hiatus hernia are rec-ognized. In the commonest, type I orsliding hernia, the distal esophagus,gastroesophageal junction and stom-ach ascend through the esophagealhiatus into the thorax.6 Type II orparaesophageal hernia is rare and in-volves a hernial sac, usually containingstomach, extending into the medi-astinum parallel to the esophagus,with the gastroesophageal junction re-maining in its normal position.7,8 Withenlargement of a type II hernia, acombined or type III hiatus hernia canresult as the gastroesophageal junctionascends into the thorax.9 Other organssuch as colon, small intestine, spleenand pancreas may enter the hernial sacresulting in a type IV hernia.9 Chronicincrease in intra-abdominal pressure,such as that resulting from obesity,pregnancy and the presence of an ab-dominal mass, have been implicated inthe development of hiatus hernias.2,6

The development of a massive hiatushernia is thought to be the result ofthe stomach being pushed by intra-

abdominal pressure and pulled by neg-ative intrathoracic pressure through ayielding hiatus, generally a result ofgradual progression of a sliding her-nia.4 The fundus and body of thestomach usually serve as the lead pointfor this ascent into the thorax.2,4,7 Theresultant intrathoracic viscera includethe fundus within the hernia. Theomentum and transverse colon may bepulled up during the process; the py-lorus usually remains in the abdomenbecause of its relationship with thefixed duodenum and pancreas.2,4,7

Massive hiatus hernia may beasymptomatic or may present with avariety of symptoms.1,2 Symptoms andsigns described as peculiar to massiveincarcerated hernias include postpran-dial precordial distress, upper gas-trointestinal bleeding, severe dyspneaand complete obstruction.4 The po-tential for volvulus and subsequent se-vere sequelae mandate surgical inter-vention.2,4,7

Our case was unusual in its putativeetiology, presentation and operativefindings. The mobile pylorus and firstpart of the duodenum could indicatea preexisting hiatal defect, yet the pa-tient had never experienced any symp-toms of hiatus hernia before the de-scribed event and only remnants of ahernial sac were found. The displace-ment of the viscera into the thorax ap-pears to have been caused by a singleepisode of strenuous physical activity,the kind usually associated with in-guinal and femoral hernias.1 The factthat the gastroesophageal junctionand fundus were in their normal posi-tions without obstruction was also un-usual, because the development ofmassive hiatus hernia is almost alwaysassociated with displacement of either

the fundus alone or both structures.4,7,9

Finally, the patient’s ability to toleratethe gastric outlet and colonic obstruc-tion for 30 days is remarkable.

References

1. Carbonell JF, Sanchez JL, Peris RT,Ivorra JC, Del-Bano MJ, Sanchez CS,et al. Risk factors associated with in-guinal hernias: a case control study.Eur J Surg 1993;159(9):481-6.

2. Skinner DB, Belsey RHR, Russell PS.Surgical management of esophageal re-flux and hiatus hernia: long-term re-sults with 1030 patients. J Thorac Car-diovasc Surg 1967;53:33-54.

3. Gahagan T. Hiatus hernia withoutesophageal reflux. Arch Surg 1967;95(5): 595-605.

4. Pearson FG, Cooper JD, Ilves R, ToddTRJ, Jamieson WRE. Massive hiatalhernia with incarceration: a report of53 cases. Ann Thorac Surg 1983;35(1): 45-51.

5. Maingot R, editor. The management of abdominal operations. New York:Macmillan; 1953. p. 684.

6. Allison PR. Reflux esophagitis, slidinghiatal hernia, and the anatomy of repair.Surg Gynecol Obstet 1951;92:419-31.

7. Ozdemir IA, Burke WA. Ilkins PA.Paraesophageal hernia: a life threaten-ing disease. Ann Thorac Surg 1973;16:547-54.

8. Ellis FH, Crozier RTE, Shea JA. Para -esophageal hiatus hernia. Arch Surg1986;121:416-20.

9. Skinner DB. Hiatal hernia and gastro -esophageal reflux. In: Sabiston DC, editor. Textbook of surgery. 13th ed.Toronto: WB Saunders; 1986. p. 753-66.

CASEY AND CASEY

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