How can a hiatal hernia mask heart problems. What are the symptoms of hiatal hernia that overlap with heart issues. Why is it crucial to investigate chest pain thoroughly, even when a hernia is present. How did one man’s persistence lead to a life-saving diagnosis.

Understanding Hiatal Hernia: More Than Just Digestive Discomfort

A hiatal hernia occurs when the upper part of the stomach pushes through the diaphragm, the muscle separating the chest and abdominal cavities. While common, especially in older adults, this condition can sometimes mask more serious health issues, as demonstrated by Nathan Emmons’ harrowing experience.

Dr. Christian Mendez, a gastroenterologist at Mayo Clinic Health System, explains: “Hiatal hernias are common in Western countries. The frequency of hiatal hernias increases with age from 10% in patients younger than 40 to 70% in patients older than 70 years. However, only 9% have symptoms.”

Common Symptoms of Hiatal Hernia

• Heartburn
• Regurgitation of food or liquids
• Difficulty swallowing
• Chest or abdominal discomfort
• Early satiety (feeling full quickly)

These symptoms can be mistaken for other conditions, making diagnosis challenging. In Nathan’s case, his hiatal hernia symptoms masked a potentially life-threatening heart condition for years.

The Deceptive Nature of Chest Pain: When Hernia Symptoms Hide Heart Problems

Nathan Emmons, a 44-year-old police officer from Barron, Wisconsin, experienced recurring chest pain and vomiting for years. Initially diagnosed with a hiatal hernia, his symptoms were attributed to this digestive condition. However, the persistence and severity of his symptoms eventually led to a more thorough investigation.

Can chest pain from a hiatal hernia be distinguished from heart-related chest pain? While both conditions can cause discomfort in the chest area, there are some key differences:

• Hiatal hernia pain often worsens after eating or when lying down
• Heart-related chest pain typically intensifies with physical exertion
• Hiatal hernia pain may be relieved by antacids; heart pain usually is not
• Heart-related pain may radiate to the arm, jaw, or back

In Nathan’s case, his symptoms were triggered by physical exertion, a red flag that was eventually recognized by his healthcare providers.

The Importance of Comprehensive Medical Evaluations: Looking Beyond the Obvious

Nathan’s journey to an accurate diagnosis highlights the critical need for thorough medical evaluations, especially when symptoms persist or worsen. Dr. Mendez’s decision to look beyond the gastroenterological symptoms proved crucial.

Why is it essential for healthcare providers to consider multiple potential causes for persistent symptoms? This approach can:

1. Uncover underlying conditions that may be masked by more apparent issues
2. Prevent delays in diagnosis and treatment of serious health problems
3. Ensure patients receive comprehensive care addressing all aspects of their health
4. Potentially save lives by identifying critical conditions early

Dr. Mendez’s thorough approach led him to recommend a stress test for Nathan, despite the initial focus on his digestive symptoms. This decision ultimately revealed the true nature of Nathan’s condition.

Stress Tests: A Crucial Tool in Diagnosing Hidden Heart Conditions

The stress test recommended by Dr. Mendez proved to be a turning point in Nathan’s diagnosis. But what exactly is a stress test, and how does it help identify heart problems?

A stress test, also known as an exercise stress test, helps doctors understand how well a patient’s heart functions during physical activity. It involves monitoring the heart’s electrical activity, blood pressure, and other vital signs while the patient exercises on a treadmill or stationary bike.

Key Aspects of a Stress Test

• Monitors heart rhythm and rate during exertion
• Measures blood pressure response to exercise
• Assesses overall cardiovascular fitness
• Can reveal blockages in coronary arteries
• Helps determine the need for further cardiac testing

In Nathan’s case, the stress test revealed significant issues with his heart function during exercise, prompting immediate action from his healthcare team.

Interpreting Stress Test Results: When Alarm Bells Ring

Dr. Joel Beachey, a cardiologist at Mayo Clinic Health System, interpreted Nathan’s stress test results. The findings were alarming and indicative of a serious heart condition.

What specific signs in a stress test indicate potential heart problems? Dr. Beachey explains:

• Ischemic changes: Findings that suggest decreased blood flow to the heart
• Regional wall motion abnormalities: Parts of the heart not squeezing effectively
• Decreased ejection fraction: A marker of reduced heart-pumping function

These findings, particularly when they occur during exercise, can indicate significant blockages in important coronary arteries, such as the left main or left anterior descending coronary artery.

Why didn’t previous tests reveal Nathan’s heart condition? Dr. Beachey clarifies that echocardiogram results can appear normal when performed at rest, as Nathan’s heart issues only manifested during physical exertion.

The Silent Threat: Understanding Coronary Artery Disease

Nathan’s case brings to light the serious nature of coronary artery disease (CAD), a condition that can develop silently over years before causing noticeable symptoms. But what exactly is CAD, and why is it so dangerous?

Coronary artery disease occurs when the arteries that supply blood to the heart muscle become narrowed or blocked by plaque buildup. This reduced blood flow can lead to various heart problems, including:

• Angina (chest pain)
• Heart attack
• Heart failure
• Arrhythmias (irregular heartbeats)

Risk factors for CAD include:

1. High blood pressure
2. High cholesterol
3. Smoking
4. Diabetes
5. Obesity
6. Physical inactivity
7. Family history of heart disease

In Nathan’s case, his family history of coronary artery disease was a significant risk factor that prompted Dr. Mendez to recommend further cardiac testing.

The Importance of Patient Advocacy and Persistence in Healthcare

Nathan Emmons’ story underscores the critical role that patients play in their own healthcare journey. His persistence in seeking answers, even when initial tests came back normal, ultimately led to the discovery of his life-threatening heart condition.

How can patients effectively advocate for their health? Consider these strategies:

• Keep detailed records of symptoms, including triggers and duration
• Don’t hesitate to seek second opinions or additional testing
• Communicate openly and honestly with healthcare providers
• Ask questions and seek clarification on diagnoses and treatment plans
• Trust your instincts if you feel something is wrong, despite normal test results

Nathan’s willingness to undergo additional testing, even when he believed his symptoms were related to his hernia, played a crucial role in uncovering his heart condition.

Multidisciplinary Approach: The Key to Comprehensive Healthcare

The collaboration between gastroenterology and cardiology in Nathan’s case highlights the importance of a multidisciplinary approach in healthcare. Dr. Mendez’s decision to consider cardiac issues, despite Nathan’s initial gastrointestinal diagnosis, proved life-saving.

Why is a multidisciplinary approach beneficial in complex medical cases?

1. It allows for a more comprehensive evaluation of symptoms
2. Different specialists can offer unique perspectives on a patient’s condition
3. It can lead to more accurate diagnoses, especially in cases with overlapping symptoms
4. Collaborative care can result in more effective treatment plans
5. It reduces the risk of missed diagnoses or delayed treatment

In Nathan’s case, the collaboration between his primary care provider, gastroenterologist, and cardiologist was crucial in identifying and addressing his heart condition.

Living with a Dual Diagnosis: Managing Hiatal Hernia and Heart Disease

For patients like Nathan who are diagnosed with both a hiatal hernia and heart disease, managing these conditions simultaneously can be challenging. However, with proper care and lifestyle modifications, it’s possible to effectively manage both conditions.

Strategies for Managing Hiatal Hernia

• Eating smaller, more frequent meals
• Avoiding trigger foods that exacerbate symptoms
• Maintaining a healthy weight
• Elevating the head of the bed when sleeping
• Taking prescribed medications as directed

Heart Disease Management Techniques

• Following a heart-healthy diet low in saturated fats and sodium
• Engaging in regular, physician-approved exercise
• Quitting smoking and limiting alcohol consumption
• Managing stress through relaxation techniques
• Taking prescribed cardiac medications consistently

By addressing both conditions, patients can improve their overall quality of life and reduce the risk of complications from either condition.

The Road to Recovery: Life After Diagnosis

For Nathan Emmons, the diagnosis of his heart condition marked the beginning of a new chapter in his life. While the discovery was undoubtedly frightening, it also provided an opportunity for life-saving treatment and a renewed focus on health.

What does recovery typically involve for patients diagnosed with coronary artery disease?

1. Medical interventions: This may include medications to manage heart function, reduce cholesterol, or prevent blood clots.
2. Lifestyle changes: Adopting a heart-healthy diet, increasing physical activity, and quitting smoking are often crucial steps.
3. Cardiac rehabilitation: Supervised exercise programs and education can help patients recover and prevent future heart problems.
4. Regular follow-ups: Ongoing monitoring by cardiologists ensures the effectiveness of treatment and allows for adjustments as needed.
5. Emotional support: Coping with a serious diagnosis can be challenging, and many patients benefit from counseling or support groups.

For patients like Nathan, who also have a hiatal hernia, recovery may involve managing both conditions simultaneously, requiring coordination between different medical specialists.

Preventing Future Health Crises: The Role of Regular Check-ups and Screenings

Nathan Emmons’ experience serves as a powerful reminder of the importance of regular health check-ups and appropriate screenings, especially for individuals with risk factors for heart disease.

How can regular check-ups and screenings help prevent serious health issues?

• Early detection of potential problems before they become severe
• Monitoring of known risk factors, such as high blood pressure or cholesterol
• Opportunity to discuss any new or changing symptoms with healthcare providers
• Adjustments to treatment plans based on current health status
• Education about preventive measures and lifestyle modifications

For individuals with a family history of heart disease, like Nathan, more frequent or specialized screenings may be recommended. These might include:

1. Regular blood pressure checks
2. Lipid panel tests to monitor cholesterol levels
3. Electrocardiograms (ECGs) to assess heart rhythm
4. Stress tests to evaluate heart function during exercise
5. Coronary calcium scans to detect early signs of plaque buildup

By staying proactive about their health, individuals can significantly reduce their risk of experiencing life-threatening conditions like the one Nathan faced.

The Power of Community Support in Health Crises

Nathan Emmons’ story is not just about medical diagnosis and treatment; it’s also a testament to the power of community support during health crises. As a long-time community servant, both as a pastor and police officer, Nathan had built strong connections within Barron, Wisconsin.

How can community support benefit individuals facing serious health challenges?

• Emotional support: Knowing others care can provide comfort and reduce stress
• Practical assistance: Help with daily tasks can allow patients to focus on recovery
• Motivation: Community encouragement can inspire patients to adhere to treatment plans
• Reduced isolation: Social connections can combat feelings of loneliness during recovery
• Shared resources: Communities can provide information and access to local health services

The motto of Barron, Wisconsin – “Be kind. Be strong. Be together. Be Barron.” – exemplifies the spirit of community support that can make a significant difference in an individual’s health journey.

Lessons Learned: The Importance of Listening to Your Body

Nathan Emmons’ experience offers valuable lessons for everyone about the importance of paying attention to one’s body and persistently seeking answers when something doesn’t feel right.

What key takeaways can we glean from Nathan’s story?

1. Don’t ignore persistent symptoms, even if initial tests come back normal
2. Be aware that symptoms of one condition can mask another, more serious problem
3. Communicate openly and thoroughly with healthcare providers about all symptoms
4. Don’t hesitate to seek second opinions or additional testing if concerns persist
5. Know your family health history and share it with your healthcare providers
6. Regular check-ups and appropriate screenings are crucial for early detection of health issues

By being proactive about their health and advocating for thorough evaluations, individuals can potentially avoid the kind of prolonged, undiagnosed condition that Nathan experienced.

The Future of Diagnostic Medicine: Integrating Technology and Human Expertise

Nathan’s case highlights both the challenges and advancements in diagnostic medicine. While his condition went undetected for years, it was ultimately uncovered through a combination of persistent investigation and advanced medical testing.

How is diagnostic medicine evolving to better detect complex or hidden conditions?

• Advanced imaging technologies providing more detailed views of internal organs
• Artificial intelligence algorithms assisting in interpreting medical data
• Genetic testing offering insights into inherited risk factors
• Wearable devices monitoring vital signs and activity levels continuously
• Integrated electronic health records allowing for more comprehensive patient histories

Despite these technological advancements, Nathan’s case underscores the continued importance of thorough clinical evaluations and the willingness of healthcare providers to look beyond initial diagnoses when symptoms persist.

As medical technology continues to advance, the integration of these tools with the expertise and intuition of healthcare professionals will be crucial in providing comprehensive, accurate diagnoses and treatment plans for patients with complex medical conditions.

Hernia symptoms hide heart condition

Patient Stories

Thursday, June 9, 2022

Topics in this Post

• Heart Health
• Gastrointestinal Health

The motto for the City of Barron, Wisconsin, is: “Be kind. Be strong. Be together. Be Barron.” Nathan Emmons has embraced this motto in all that he does.

Over the span of 44 years, he has focused on bringing people together and caring for the community. He is a 17-year veteran of the Barron Police Department and founded the city’s K9 program. Before that, he was a pastor for 27 years, counseling families during times of joy and crisis.

While he was focusing on the community’s heart, his own heart was hiding a secret, life-threatening condition.

Concerning symptoms

In 2016, Nathan was working a night shift at the police department when he began experiencing chest pain. An otherwise healthy person, he was alarmed and went to the Emergency Department at Mayo Clinic Health System in Barron. The results from an echocardiogram and blood work were normal, and he was sent home to recover.

Nathan continued to have sporadic periods of chest pain, nausea and vomiting after periods of physical exertion.

“I would have chest pain and puking, but then it would be fine,” he says. “I found that if I drank water, it would relieve my symptoms. So I just carried water with me all the time.”

Hernia discovery

While he was controlling most of his symptoms, Nathan really wanted to get to the root of the problem. In 2019, Brad Kruger, a Family Medicine physician assistant and Nathan’s primary care provider, referred him to Gastroenterology for additional testing.

An endoscopy showed that Nathan had a hiatal hernia. This occurs when the upper part of the stomach budges through the large muscle separating the abdomen and chest.

“Hiatal hernias are common in Western countries. The frequency of hiatal hernias increases with age from 10% in patients younger than 40 to 70% in patients older than 70 years. However, only 9% have symptoms,” says Christian Mendez, M.D., a gastroenterologist at Mayo Clinic Health System in Barron and Eau Claire, Wisconsin. “Large hiatal hernia can cause heartburn, regurgitation of food or liquids into the mouth, difficulty swallowing, chest or abdominal discomfort, and early satiety.”

Over time, Nathan’s symptoms became more regular, and drinking water no longer provided relief.

“By the end of 2021, it was taking less effort to cause symptoms,” he says. “Even brushing snow off the car or running the K9 dog around cars for drug sniffs triggered chest pain and vomiting,” Nathan says. “I always had to carry a bottle of water with me.”

In January, Nathan decided to have Dr. Mendez reevaluate his hernia. After a repeat endoscopy, Dr. Mendez confirmed that Nathan had a small hiatal hernia and inflammation of the stomach lining.

Failing stress test

These conditions explained Nathan’s nausea and vomiting but not his chest pain. Dr. Mendez wanted to dig deeper.

“As the upper endoscopy findings didn’t explain his symptoms, I asked him about risks factors for heart disease, such as cholesterol, tobacco use and family history of cardiac disease. His family history of coronary artery disease was positive in several relatives,” says Dr. Mendez. “I immediately thought about an atypical presentation of coronary artery disease and recommended a stress test.”

While not excited about another test, Nathan was happy that Dr. Mendez focused on more than just his gastrointestinal symptoms.

“He had a genuine interest in me as a person. He asked questions about the location of my pain, to describe it and my overall health history,” says Nathan. “He took the time and thought outside of the box. At least outside of his specialty.”

On April 14, he traveled to Mayo Clinic Health System in Eau Claire for an exercise stress test that would show how his heart was working during physical activity.

“I wasn’t worried because, in my mind, I was dealing with a hernia — not a heart problem,” recalls Nathan. “But then I had a lot of pain during the stress test. I would score the pain higher than a 10, if possible. I failed it miserably.”

After the test, Joel Beachey, M.D., a Mayo Clinic Health System cardiologist, explained the results to Nathan and recommended immediate treatment.

“His stress test was markedly positive for ischemic changes, or findings that suggest decreased blood flow to the heart,” says Dr. Beachey. “When he exercised, he developed regional wall motion abnormalities, meaning that parts of his heart were not squeezing effectively. His ejection fraction — a marker of heart-pumping function — also decreased. This is a concerning warning sign of a significant blockage, usually in an important artery like the left main or left anterior descending coronary artery.”

He also explained that previous echocardiogram tests results appeared normal because they were completed while Nathan was at rest.

“If arteries are not completely blocked, patients may be getting normal blood flow during times when they are not active,” says Dr. Beachey. “Thus, the ischemic changes we look for on an echocardiogram may not be present.”

Treatment for blocked arteries

Dr. Beachey recommended that Nathan have a coronary angiogram right away and not wait until after the Easter holiday weekend. This procedure uses X-ray imaging to see if the heart’s blood vessels are restricted.

“In meeting with him and reviewing his history, I became concerned that his symptoms were becoming more unstable. He was describing rapid recent progression of symptoms with significant limitations with decreasing amounts of activity,” he says. “While he had been having symptoms for months, the progression concerned me about his risk for an acute coronary syndrome event soon. I recommended that we proceed with coronary angiogram, and, thankfully, we were able to arrange for an angiogram the following day.”

On April 15, Nathan’s wife lined up someone else to play the organ during Good Friday church service so she could drive him to Eau Claire for the coronary angiogram. Mayo Clinic Health System cardiologist D. Fearghas O’Cochlain, M.D., injected dye into Nathan’s vessels and discovered the source of his discomfort: significant blockages in four major arteries of his heart.

“The angiogram showed that Mr. Emmons had severe coronary artery disease involving multiple vessels,” says Dr. O’Cochlain. “He had 90% blockages in the proximal and midleft anterior descending arteries, plus left circumflex artery. Mr. Emmons also had a 70% blockage of his first diagonal artery.”

Dr. O’Cochlain placed four stents in the narrowed arteries to increase blood flow around Nathan’s heart. This included a stent in the left anterior descending artery, sometimes called the “widow-maker.”

“The left anterior descending artery provides blood supply to a large portion of the left ventricle,” explains Dr. Beachey. “Heart attacks involving this artery have the worst prognosis among all types of heart attacks and have the highest rates of sudden death, due to the significant portion of heart muscle that can be involved. “

When Nathan woke up in recovery, he learned about the extent of the blockages. He was relieved the care team was able to restore blood flow.

“To say I was shocked would be an understatement,” he says. “I eat healthy and take supplements that are good for my heart, so I didn’t expect it to be that bad.”

Dr. Beachey explains Nathan didn’t have any of the typical risk factors for artery blockages like high blood pressure, high cholesterol, smoking or diabetes.

“Mr. Emmons had no specific risk factors, aside from family history. He has been otherwise healthy and active without prior known significant medical issues,” says Dr. Beachey. “I suspect his coronary disease is strongly genetically influenced, as he reported a family history of heart attacks.”

Dr. O’Cochlain explains that symptoms of heartburn, acid reflux and chest pain overlap due to reduced blood flow to the heart. This can lead some people to downplay symptoms and not seek medical care.

“Many people interpret the symptom ‘chest pain’ as a sharp localized discomfort similar to a knife. However most do not experience cardiac discomfort in this way,” he says. “It’s often pressure, burning, poorly localized discomfort or a cramp. Because it is not what they think of as ‘pain,’ people may either dismiss it or attribute it to something else, such as heartburn.”

Welcome visit during recovery

Nathan got another surprise while in the recovery area: a visit from Dr. Mendez.

“I wanted to celebrate with him and his wife,” says Dr. Mendez. “I knew he was coming for his cardiac intervention, and I like to follow up with my patients after referring to other specialties.”

This gesture meant a lot to the Emmons family.

“He had no other reason to be there, except that he cared,” Nathan says. “It meant a lot to me and my wife that he checked in on us. When she realized who he was, she gave him a big hug and told him thank you.”

Next steps

After the angiogram and stent placements, Nathan was able to recover at home. Shortly after, he began cardiac rehabilitation to rebuild the strength and stamina of his heart.

Once recovered, he will discuss with Dr. Mendez treatment options for his hiatal hernia. Nathan is hoping to get the green light to spend time golfing and fishing this summer.

Reflecting on the last months, Nathan says he feels blessed to have met Dr. Mendez and to have received expert, timely care from the Cardiology team.

“Had he not recommended the stress test, I don’t want to think about what could have happened. Any one of the times that I pushed through the pain before could have easily been my last day,” he says. “God kept me here for a reason.”

Topics in this Post

• Heart Health
• Gastrointestinal Health

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A Large Intrathoracic Hiatal Hernia as a Cause of Complete Heart Block

• Journal List
• Case Rep Cardiol
• v. 2021; 2021
• PMC8286180

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Case Rep Cardiol. 2021; 2021: 6697016.

Published online 2021 Jul 9. doi: 10.1155/2021/6697016

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Author information Article notes Copyright and License information Disclaimer

Data Availability Statement

Hiatal hernia is a not uncommon anatomic disorder resulting in portions of the bowel occupying space in the thoracic cavity. There are a number of antecedent risk factors including obesity but not hiatal hernias resulting in symptoms. When symptoms do occur, they can include chest pain, nausea, abdominal pain, and gastroesophageal reflux. Cardiac arrhythmias have also been reported as associated conditions resulting from a hiatal hernia. To date, however, a complete heart block secondary to a hiatal hernia has not been reported. An 88-year-old female with a history of GERD (gastroesophageal reflux disease) was found to have a large hiatal hernia at endoscopy after she presented to the emergency department with nausea and abdominal pain. Prior to her scheduled surgical repair, she developed symptomatic third degree heart block which resolved with nasogastric tube deflation of the gastric contents. After surgical repair of the hiatal hernia, she developed episodes of atrial fibrillation with rapid ventricular response and was started on diltiazem. She eventually converted back to normal sinus rhythm and remained dysrhythmia free. In addition to other known arrhythmias associated with hiatal hernia, a complete heart block can also be seen. Acute management requires deflation of the chest occupying hernia. This appears to be the one of the first reported cases of complete heart block caused by hiatal hernia.

Hiatal hernia is a common pathology which increases in incidence with age. It is associated with (GERD) gastroesophageal reflux disease, a widespread condition that may present as atypical chest pain. Cases of patients with large hiatal hernia causing electrocardiographic changes have been well documented, manifesting as atrial fibrillation [1], atrial flutter [2], ST segment elevation [3], and others, but to date, there have been no reports of complete heart block caused directly by hiatal hernia. Here, we discuss one of the first reported documented cases of a hiatal hernia causing complete heart block.

An 88-year-old female with a past medical history of gastroesophageal reflux disease, hypertension, and anxiety presented to the emergency department with nausea and abdominal pain after chest X-ray and CT (computed tomography) scan of the abdomen performed at an outside facility showed a large hiatal hernia with possible volvulus or gastric obstruction (Figures –) at an outside facility. She had no past history of known treated cardiac dysrhythmia. Her vital signs were normal, and physical exam was only remarkable for epigastric abdominal pain. The patient was admitted and evaluated with GI series barium study, which showed a thoracic stomach with gastric obstruction. An EGD (esophagogastroduodenoscopy) was performed which confirmed the presence of a large hiatal hernia. Surgical intervention was planned to correct the anatomical defect, but the day prior to her planned surgery, she ate a large meal and became hypotensive, with her 12-lead ECG showing complete heart block (). The patient was promptly sent to the intensive care unit (ICU) for monitoring. She had a nasogastric tube inserted for decompression, which converted the complete heart block back to normal sinus rhythm (). Three days later, she underwent successful laparoscopic robotic-assisted hiatal hernia repair and gastrostomy tube placement. Postoperatively, the patient had no recurrence of complete heart block, and she was transferred from the ICU to the cardiac unit. There, she proceeded to experience episodes of atrial fibrillation with rapid ventricular response. Echocardiography was performed and was significant for an ejection fraction of 65-69%, moderate aortic stenosis, and pulmonary hypertension. The patient was placed on diltiazem and eventually converted back to normal sinus rhythm. She was discharged to a skilled nursing facility with diltiazem and apixaban and was instructed to follow up with cardiology and thoracic surgery as an outpatient.

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Upright chest X-ray showing large intrathoracic hiatal hernia between the yellow arrows.

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Transverse chest CT of the abdomen showing large hiatal hernia with concern for gastric volvulus or gastric outlet obstruction. The large hernia is between the yellow arrows. The heart is “H,” and the debris in the bowel is “D.”

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Coronal CT of chest and abdomen showing the large hiatal hernia located above the diaphragm with the liver “L” apparent.

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12-lead EKG showing complete heart block.

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12-lead EKG obtained after NG tube placement and patient reverting back to normal sinus rhythm.

Hiatal hernia is defined as an abnormal protrusion of the stomach above the diaphragm from the esophageal hiatus. While hiatal hernias most often only involve protrusion of the stomach as the protruding organ, it may also contain the transverse colon, small bowel, spleen, or some combination of these. Risk factors for hiatal hernias include obesity, age-related changes in the diaphragm, and increased intra-abdominal pressure due to conditions like chronic coughing, constipation, exercising, and lifting heavy objects. Hiatal hernias may be asymptomatic or may present with gastroesophageal reflux disease, dysphagia, odynophagia, hoarseness, or asthma. Extreme cases may cause compression of the heart and pulmonary veins, leading to a presentation of pulmonary edema and cardiac failure [4]. Atrioventricular (AV) block is a cardiac electrical disorder defined as impaired (delayed or absent) conduction from the atria to the ventricles. The severity of the conduction abnormality is described in degrees: first-degree, second-degree, type I (Wenckebach or Mobitz I) or type II (Mobitz II), and third-degree (complete) AV block [5].

Large hiatal hernias can induce electrocardiographic changes, and atrial tachycardia, atrial fibrillation, supraventricular tachycardia, atrial flutter, and T wave changes have all been previously reported, but the exact mechanism of such arrhythmias is not well understood. One current hypothesis suggests that it is the increase in the direct or indirect pressure on the global surface of the heart by the hernia which causes these electrical changes seen on EKG [6]. Another suggests that it is actually due to the compression on the heart by the thoracic stomach causing anatomic conduction block or disruption in the vagal nerve [7]. Intense vagal stimulation has been described before to causing syncope and bradycardia in “swallow syncope syndrome. ” The pathophysiologic explanation is due to the common innervation of the esophagus and heart by the vagus nerve. The mechanoreceptors in the esophagus sense the distension and send signals along the esophageal plexus vagus nerve to the brainstem and then efferent impulses from the brainstem reach the sinoatrial (SA) node and the AV node, that leads to developing various bradyarrhythmias and temporary reduction of the cardiac output, which in result leads to cerebral hypoperfusion and syncope [8].

The presented patient had a huge hiatal hernia, and the food intake was the trigger for her hypotension and telemetry at that time it showed complete heart block. After the patient had a successful laparoscopic surgery and hiatal hernia repair, she did not develop any recurrent AV blocks. She did have a brief atrial fibrillation episode that converted back to normal sinus rhythm, which can be a postoperative episode as the patient has no history of AFib or palpitations before. Our patient was monitored on telemetry for days prior to discharge, and no recurrent events were recorded. She followed with cardiology outpatient and was on Holter monitor for 2 weeks which showed no significant events and leads to the conclusion that the surgical repair to the hernia resulted in complete resolution of the AV block.

We hypothesize that the hernia has caused a mechanical conduction block on the AV node or an increase in the firing of the vagal nerve by the mechanism mentioned above.

We present a rare case of a large hiatal hernia causing complete heart block and symptomatic hypotension resolving with nasogastric tube placement. To our knowledge, this appears to be one of the first cases to report these findings. We performed a MEDLINE search of the English language literature via PubMed from January 1, 1946 to the present, using the MeSH terms and keywords “hiatal hernia,” “heart block,” and “atrioventricular block.” We could find, however, no cases of complete heart block associated with hiatal hernia. We concluded that the symptomatology of the patient was related to compressive effects caused by the hernia.

The clinical and treatment data used to support the findings of this study are included within the article.

The authors declare that they have no conflicts of interest.

1. Armaganijan L., Patel D., Lopes R. D., et al. Gastroesophageal reflux and atrial fibrillation: Is there any correlation? Expert Review of Cardiovascular Therapy. 2012;10(3):317–322. doi: 10.1586/erc.11.198. [PubMed] [CrossRef] [Google Scholar]

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Articles from Case Reports in Cardiology are provided here courtesy of Hindawi Limited

Diaphragmatic hernia | Morozovskaya DGKB DZM

Diaphragmatic hernia is a developmental anomaly characterized by the presence of a congenital defect of the diaphragm, through which, in the prenatal period, the abdominal organs (intestinal loops, stomach, spleen, sometimes part of the liver) move into the chest. The incidence of this developmental anomaly is 1 case per 2200 newborns (P.Puri, M.Hollwarth 2009). There are left-sided and right-sided diaphragmatic hernia, false and true, as well as eventration of the diaphragm. There are hernias of the diaphragm itself and hernias of the natural openings of the diaphragm (hiatal hernia, paraaortic). With congenital diaphragmatic hernia, there are combined anomalies in the development of other organs and systems (malformations of the nervous system, heart defects, malrotation).

Currently, the malformation is diagnosed antenatal at 18-20 weeks of fetal development. With ultrasound of the fetus in the chest, the abdominal organs are visualized, the mediastinum is displaced to the healthy side, polyhydramnios is noted.

Clinical symptoms develop a few minutes after birth as a manifestation of respiratory failure (cyanosis, rapid breathing, retraction of the sternum). It may be asymptomatic for several months or even years. The earlier the clinic of diaphragmatic hernia appears, the worse the prognosis of this disease. If a diaphragmatic hernia is suspected, immediate hospitalization in a specialized hospital is necessary.

Diagnosis of diaphragmatic hernia after birth is made on the basis of clinical examination (difficulty breathing, cyanosis, shift of heart sounds to the healthy side, weakening or absence of breathing on the side of the lesion, sunken abdomen), chest x-ray in two projections, in which chest intestinal loops, the dome of the diaphragm is not determined, the mediastinum is displaced in the opposite direction, in the abdominal cavity, the presence of gas in the intestinal loops is sharply reduced or absent.

If the diagnosis is difficult, an x-ray of the gastrointestinal tract is performed with the introduction of water-soluble contrast, in which intestinal loops are detected penetrating through the diaphragm into the chest.

Preoperative preparation is carried out in the intensive care unit. Insert a gastric tube and decompress the stomach, intubate the trachea, and provide adequate ventilation. Stabilize hemodynamic parameters.

After the child’s condition is stabilized, surgery is performed. Surgical treatment consists in moving the organs back into the abdominal cavity and suturing the diaphragm defect. In most cases, the defect can be sutured with local tissue. With a significant size of the defect, inserts made of various synthetic materials are used. After the operation, the child is in the intensive care unit, receiving the necessary treatment to maintain vital functions. The prognosis of this disease largely depends on the degree of underdevelopment of the lungs.

The current preference is for thoracoscopic surgery. This technique is less traumatic, promotes accelerated recovery in the postoperative period and provides a good cosmetic result.

Hernia, symptoms, diagnosis and treatment | Alpha

Esophageal hernia: symptoms and treatment

A hiatal hernia (hiatal hernia) is a condition in which the upper portions of the stomach and part of the esophagus enter the chest area through an opening in the diaphragm. Diaphragmatic hernia of the esophagus causes significant discomfort and interferes with a person in everyday life. Over time, the disease can provoke dangerous complications, therefore, it requires serious treatment.

Causes of disease

In childhood, a hernia of the diaphragm of the esophagus occurs due to anatomical pathologies of the formation of the fetus. The child has a displacement of the cardial part of the stomach into the chest cavity.

Possible causes of hernia of the esophagus in adults:

• weakness of the ligamentous apparatus of the digestive system;
• inflammatory diseases of the stomach: ulcer, chronic gastroduodenitis, pancreatitis, etc. ;
• pathology of the esophagus: burns of the mucosa, esophagitis, varicose veins, etc.;
• injuries of the gastrointestinal tract;
• damage caused by a prolonged increase in pressure in the abdominal cavity, for example, during heavy physical exertion;
• obesity, constipation, flatulence;
• tumors.

Diaphragmatic hernia classification

• Sliding (axial) . The fundus of the stomach and part of the esophagus slide freely into the chest cavity. Axial hernias are the most commonly diagnosed. The risk of infringement is minimal.
• Perioesophageal (paraesophageal) . Less common is a pathology in which the esophagus remains in place, and the fundus of the stomach and other abdominal organs protrude through the opening of the diaphragm. Paraesophageal hernias are often infringed, therefore, as a rule, they require surgical treatment.
• Mixed . Hernia of the esophagus of the stomach has signs of both types described above.
• Acquired short esophagus . Pathology occurs as a result of trauma and inflammatory diseases. The stomach is drawn into the mediastinum through the diaphragmatic opening.

Esophageal hernia stages

• I – the abdominal esophagus is displaced into the mediastinum, the fundus of the stomach is located close to the diaphragm.
• II – the bottom and cardia of the stomach are located in the esophagus.
• III – the stomach and part of the esophagus are displaced into the mediastinum.

Hernia symptoms

The disease can proceed for many years without severe symptoms. Most often, pathology is diagnosed during a routine examination or medical examination.

There are several non-specific symptoms of a hernia of the esophagus, in the event of which it is necessary to consult a gastroenterologist:

• Heartburn, which is aggravated by physical exertion, bending over.
• Pain behind the sternum, the cause of which is the compression of displaced organs.
• Belching with a sour or bitter taste.
• Dysphagia after swallowing food quickly or eating fried food.
• Hiccups, which may increase to vomiting.

Signs of a hernia of the esophagus are often confused with cardiac symptoms. The patient may experience persistent cough, shortness of breath, tachycardia, blanching of the skin after eating. Pain with a hernia of the esophagus can be localized in the region of the heart.

Disease diagnosis

The most informative are instrumental diagnostic methods:

• Barium X-ray . Pictures are taken in several projections. Radiography allows you to detect the protrusion of organs in the esophageal opening of the diaphragm and assess the severity of the disease.
• Computed tomography . According to the pictures, the doctor determines the size, localization of the defect. The CT image clearly shows the blood vessels and contents of the hernia.
• Fibroesogastroscopy . A thin tube with a video camera is pushed into the esophagus. The doctor on the screen sees the mucous membrane of the internal organs, can detect inflamed areas, ulcers, scars and other defects.
• ultrasound . The examination determines the degree of displacement of the boundaries of the mediastinum, heart, measure the defect of the diaphragm.
• Esophageal manometry . An examination is prescribed to assess the performance of the esophageal sphincters. Esophageal manometry helps not only in diagnosis, but also in evaluating the effectiveness of prescribed therapy.

Treatment

At stages 1 and 2, conservative treatment of esophageal hernia is indicated. To reduce heartburn, drugs are prescribed that reduce the level of acidity in the stomach, antacids. It is possible to take medications that stimulate the peristalsis of the stomach.

Proper nutrition plays an important role in treatment. The patient should divide the daily norm into 5-6 small portions, have dinner no later than 2 hours before bedtime. Fried, spicy, fatty foods, alcoholic and carbonated drinks are excluded from the diet. The menu is based on vegetable soups, boiled fish, meat, kissels, cereals, fruits. Normalization of nutrition with a hernia of the esophagus allows you to almost completely get rid of unpleasant symptoms.

In severe clinical cases, surgery is indicated. The task of the surgeon is to eliminate reflux and reduce the esophageal opening in the diaphragm. Rehabilitation after surgery takes several days. To prevent relapse, patients are advised to follow a diet, give up bad habits and avoid physical activity.

What is dangerous hernia of the esophagus without treatment:

• infringement of internal organs;
• increased reflux to vomiting;
• development of ulcers, erosion in the digestive tract;
• occurrence of internal bleeding.

Diagnosis and treatment of esophageal hernia in Nizhny Novgorod

The clinic “Alfa Health Center” invites you to undergo a comprehensive examination of the gastrointestinal tract.