Biliary Obstruction From Paraesophageal Hernia

n 83-year-old woman presented with 3 weeks of Apainless jaundice. She reported having some dyspnea after meals for the past 3 months. On examination, bowels sounds were audible from the lower half of her chest. The abdominal examination was unremarkable. Significant laboratory findings included the following: aspartate aminotransferase level, 200 U/L; alanine aminotransferase level, 150 U/L; alkaline phosphatase level, 660 U/L; and serum total bilirubin level, 20 mg/dL. Chest radiography showed loops of intestine in the thoracic cavity, representing enterothorax (Figure A). Computed tomography of the chest and abdomen showed a massive hiatal hernia with protrusion of stomach, small intestine, colon, pancreas, and a portion of common bile duct into the thoracic cavity (Figure B). The gall bladder was distended massively with severe intrahepatic and extrahepatic biliary dilatation (Figure B, red arrow). A partial volvulus of common bile duct was present, with the duct being twisted and running cephalad with acute tapering at the hiatus; thus causing obstructive jaundice (Figure B, green arrow). Figure C (red arrows) shows the diaphragm on both sides with massive hiatal hernia. A percutaneous transhepatic cholangiography was performed for biliary decompression. Figure D shows the cholangiogram with a biliary catheter in place, the common bile duct running superiorly, with an abrupt narrowing at the level of the hiatus in comparison with the computed tomography scan image, and finally ending in the duodenum(arrow; C, commonbile duct; D, duodenum; L, left hepatic duct; R, right hepatic duct; S, stomach). Laparotomy confirmed type IV paraesophageal hernia. Fifty centimeters of small bowel was resected because of signs of strangulation. The hernia sac was removed, and the contents were replaced into the abdominal cavity. The crura were sutured with a mesh, and a Nissen fundoplication was performed. Repeat imaging did not show any narrowing of the common bile duct. Jaundice improved immediately postoperatively. Jaundice caused by biliary obstruction is an extremely rare presentation of a paraesophageal hiatal hernia. It first was reported in 1986. However, only 2 cases have been reported thereafter. A massive paraesophageal hernia involving the intestine eventually may lead to an abnormal cephalad course of common bile duct through diaphragmatic hiatus and may result in extrinsic compression of the bile duct. Percutaneous cholangiography is important to confirm the anatomic position of the bile duct as well as for biliary decompression to prevent cholangitis. Evidence of jaundice warrants early surgical correction of the paraesophageal hernia. References 1. Llaneza PP, Salt WB 2nd, Partyka EK. Extrahepatic biliary obstruction complicating a diaphragmatic hiatal hernia with intrathoracic gastric volvulus. Am J Gastroenterol 1986;81:292–294. 2. Caldeiro JC, Curcio A, Gigena VC, et al. Choledochal semi volvulus with jaundice due to hiatal hernia. Initial percutaneous management. Acta Gastroenterol Latinoam 2001;31:329–332. 3. Lamouliatte H, Bernard PH, Lefebvre P, et al. Hernie hiatale avec volvulus intrathoracique. Une cause rare d’ictere obstructif. Gastroenterol Clin Biol 1992;16:89–91.