Mary Fowler, aged 68, presents to the emergency department, or ED, with vomiting and abdominal pain and distention.
Mary has a history of a paraesophageal hiatal hernia with symptoms of gastroesophageal reflux disease, or GERD, which she normally manages with lifestyle modifications and acid-reducing medications.
Her symptoms worsened over the last 2 days, and she has been unable to keep food or liquid down over the last 24 hours.
Mary is diagnosed with a large incarcerated paraesophageal hiatal hernia, confirmed with an abdominal X-ray and computerized tomography, or CT scan.
She will be cared for in the ED while she awaits surgical repair of her hernia.
A hiatal hernia occurs when part of the stomach moves up, or herniates, into the chest through the hiatus, which is the opening in the diaphragm for the esophagus as it enters the abdominal cavity.
Underneath the diaphragm, the esophagus then connects with the stomach to form the gastroesophageal junction and the lower esophageal sphincter, or LES, a ring of muscles that opens to allow food and liquids into the stomach and closes to keep gastric contents from coming back up through the esophagus.
There are two main types of hiatal hernias.
The most common type is a sliding hernia, where the gastroesophageal junction slides up and down through the hiatus.
Less common are paraesophageal hernias, where parts of the stomach roll up through the hiatus, forming a pocket next to the esophagus.
The risk of developing a hiatal hernia increases if the diaphragm is weakened from trauma, abdominal surgery, or smoking.
Likewise, anything that increases pressure inside the abdomen, like coughing, obesity, pregnancy, straining, or heavy lifting increases the risk of hernia development.