July 2025 Medical Image of the Month: A Case of Severe Hiatal Hernia Presenting as Atypical Chest Pain

Figure 1. Portable AP chest x-ray demonstrates a heart size at the upper limits of normal with left pericardiac pulmonary opacity and opacity in the left retrocardiac region, likely related to a large hiatal hernia. To view Figure 1 in a separate, enlarged window click here.
Figure 2. Coronal (A,B) and axial (C) reconstructions from a CT of the Abdomen and Pelvis with IV contrast performed at time of admission demonstrates a large hiatal hernia with an intrathoracic debris-filled stomach (*) and a small diaphragmatic hernia neck (arrows). Also note areas of myocardial thinning and decreased enhancement in the LV apex (arrowheads) consistent with the patient’s history of prior myocardial infarction. To view Figure 2 in a separate, enlarged window click here.
A 73-year-old woman with a past medical history including coronary artery disease (CAD), prior myocardial infarction (MI), cardiomyopathy, hypertension, obstructive sleep apnea (OSA) on CPAP, gastroesophageal reflux disease (GERD),and a history of pulmonary embolism on apixaban presented to the emergency department with six hours of chest pain. She described the pain as pressure-like, radiating from beneath the left breast to the left axilla and back. She also reported associated nausea without vomiting and poor oral intake but maintained normal bowel movements. She denied fever, chills, dyspnea, vomiting, diarrhea, constipation, or abdominal pain. The patient recalled a similar episode during her MI ten years prior, prompting her to seek medical care.
Vital signs were stable. Cardiac workup included serial troponins, both of which were negative (at 8 and 7 respectively), and an electrocardiogram (EKG) showing normal sinus rhythm without ST-T wave abnormalities. Chest x-ray (Figure 1) demonstrated a retrocardiac opacity suggestive of a hiatal hernia. Medical management included Maalox 30 mL, famotidine 20 mg, ondansetron 4 mg, metoclopramide 10 mg, IV acetaminophen 1 g, and IV morphine 4 mg. A CT scan of the abdomen and pelvis with contrast (Figure 2) revealed a large hiatal hernia containing the majority of the stomach and a small diaphragmatic hernia, raising concern for partial gastric obstruction. There was also mild gastric wall edema and several fluid-filled loops of small bowel with mild thickening, suggestive of possible enteritis. The patient was made NPO, and a nasogastric tube was inserted to low intermittent suction. General surgery was consulted, and cardiology assessed her to be at intermediate risk for surgery. On hospital day six, she underwent a successful robotic-assisted laparoscopic paraesophageal hernia repair with gastropexy.
Hiatal hernias are classified into four types. Type IV is the rarest and most complex, characterized by herniation of the stomach and additional abdominal organs such as the colon, small bowel, into the thoracic cavity through a widened diaphragmatic hiatus (1). This type is more prevalent in older adults due to progressive weakening of the phrenoesophageal membrane and chronic intra-abdominal pressure (2). Unlike type I sliding hernias, type IV hernias frequently present with obstructive symptoms, such as chest pain, nausea, and vomiting, and carry a high risk for complications like volvulus or strangulation. Minimally invasive approaches, including laparoscopic or robotic-assisted hernia reduction, crural closure, and gastropexy or fundoplication, are associated with favorable outcomes (3).
Varshita Goduguchinta DO, Raahi Patel DO, Ahmed Al-Mubaid MD, Mohammed Hammad MD
Department of Internal Medicine - Franciscan Health, Olympia Fields, IL
References
- Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22(4):601-16. [CrossRef] [PubMed]
- Stylopoulos N, Rattner DW. The history of hiatal hernia surgery: from Bowditch to laparoscopy. Ann Surg. 2005 Jan;241(1):185-93. [CrossRef] [PubMed]
- Mertens AC, Tolboom RC, Zavrtanik H, Draaisma WA, Broeders IAMJ. Morbidity and mortality in complex robot-assisted hiatal hernia surgery: 7-year experience in a high-volume center. Surg Endosc. 2019 Jul;33(7):2152-2161. [CrossRef} [PubMed]
Cite as: Goduguchinta V, Patel R, Al-Mubaid A, Hammad M. July 2025 Medical Image of the Month: A Case of Severe Hiatal Hernia Presenting as Atypical Chest Pain. Southwest J Pulm Crit Care Sleep. 2025;31(1):12-13. doi: https://doi.org/10.13175/swjpccs015-25 PDF