# The Hole in the Stomach

Authors: Hans Bödeker; Steffen Leinung; Henning Wittenburg; Julia Fischer; Ingolf Schiefke; Niels Teich
Journal: Diagnostic and Therapeutic Endoscopy
 (2008)

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## Abstract

A 57 year old woman was presented to the emergency department with upper abdominal pain and left sided chest discomfort. No cardiac or pulmonary cause could be determined and the patient underwent upper gastrointestinal endoscopy. Inversion of the scope to the fundus and subsequent fluoroscopy revealed a diaphragmatic hernia with a large herniation of the gastric fundus. Immediate laparotomy showed a 3 cm orifice of the diaphragm. The orifice was widened and a partial necrosis of the incarcerated fundus was resected. The patient recovered fully and was discharged 12 days after laparotomy.


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## Body

## 1. Introduction

Diaphragmatic hernia in the adult is a rare event and most commonly occurs due to a sudden pressure gradient between the peritoneal and thoracic cavities. Rarely, no specific history can be obtained. In this report, we present the endoscopic and fluoroscopic appearance as well as the intraoperative situs of an idiopathic  diaphragmatic hernia.


## 2. Case Report

A 57-year-old woman (180 cm, 60 kg) was presented to the emergency department with
upper abdominal pain and left-sided chest discomfort for a couple of days. In
addition, she reported of nausea. Upon physical examination, percussion sounds
over the left lower thorax were a bit dull and cervical lymph nodes were
palpable with a size of up to 1 cm. The abdomen was generally tender without
signs of peritonitis; bowel sounds were normal. The ECG showed no
abnormalities. Routine laboratory tests revealed mild leucocytosis and a
slightly elevated C-reactive protein level. Troponin, myoglobine, and creatine
kinase levels were within normal limits. An upper gastrointestinal endoscopy
was performed. Whereas the oesophagus, the lower stomach, and the duodenum were
without abnormalities, a small hole in the fundus was visible after inversion
of the scope (Figure1).Figure 1
Upper gastrointestinal endoscopy: inversion view into the gastric fundus.The “hole in the stomach” was intubated with a catheter and contrastdye was administered.
Fluoroscopy revealed a diaphragmatic hernia with a large herniation of the
gastric fundus (Figure2). Immediate laparotomy showed a 3 cm orifice of the
diaphragm (Figure 3). The orifice was widened and a partial necrosis of the
incarcerated fundus was resected (Figure 4). The diaphragmatic orifice was
covered with polydioxanone. The patient recovered fully and was discharged 12
days after laparotomy.Figure 2
Fluoroscopy after contrast dye application via the “hole in the stomach” revealed a large intrathoracal herniation of the gastric fundus.Figure 3
Orifice of the left part of the diaphragm (arrow).Figure 4
Partial necrosis of the incarcerated fundus (arrow).


## 3. Discussion

Nonhiatal diaphragmatic hernia in the
adult is a rare event. Commonly, it becomes symptomatic after blunt trauma,
heavy lifting, or other causes of a substantial pressure gradient between the
peritoneal and thoracic cavities. Occasionally, no specific history can be
obtained. The intrathoracic portion of the stomach may become strangulated and
necrotic and finally perforate, resulting in the development of a hydrothorax,
a gastropleural fistula, and respiratory distress [1, 2]. Therefore, in general,
immediate surgery is indicated.



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