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Requests for reprints should be addressed to Ami Schattner, MD, Faculty of Medicine, Hebrew University Hadassah Medical School, Jerusalem 91120, Israel
Department of Medicine, Laniado Hospital, Sanz Medical Centre, Netanya, IsraelFaculty of Medicine, Hebrew University Hadassah Medical School, Jerusalem, Israel
An independent community-dwelling 85-year-old nonsmoking woman was admitted with shortness
of breath and cough. Her history included hypertension, hypothyroidism, and episodic
dyspnea treated by her primary physician as bronchial asthma. On examination, she
appeared comfortable and was afebrile, with normal respiratory rate and oxygen saturation
(97%). However, bilateral wheezing and rhonchi were heard, and decreased breath sounds
on the left were noted. Heart rate was regular (85 beats per min), and her blood pressure
155/85 mm Hg without signs of heart failure. Laboratory tests were unremarkable, with
pH 7.406 and normal PCO2/bicarbonate. Chest X-ray and computed tomography (Figure 1, Figure 2) revealed a giant left-sided hiatal hernia containing the entire stomach and much
of the transverse and descending colon, compressing the lung and heart. Systemic steroids
and inhaled bronchodilators were stopped as were antibiotics for pneumonia. Together
with the patient, conservative treatment was preferred, and she was discharged home
on omeprazole.
Figure 1Erect frontal chest X-ray shows a huge hernia filling most of the left hemithorax
and bulging into the right hemithorax, significantly compressing the left lung. The
hernia contains both stomach and colon and is a hiatal hernia (compared with a left
diaphragmatic hernia) as the diaphragm is displaced inferiorly. There is no sign of
bronchial thickening (a nonspecific but common sign in asthma) or interstitial edema
(which can denote an acute asthmatic attack).
Figure 2Axial image from computed tomography (CT) of the chest scanned at the portal phase:
A giant hiatal hernia takes up most of the left hemithorax and bulges significantly
into the right hemithorax, displacing the descending aorta (curved arrow) to the right. The stomach (arrowheads) in its entirety is contained within the thorax, as well as a sizeable portion of
the transverse colon (white arrows) and descending colon (black arrow). The heart is also compressed against the anterior chest wall due to the sheer size
of the hernia.
