All That Wheezes Is Not Asthma: Giant Hiatal Hernia

      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 1
      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 2
      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.
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