Large Gastric Obstruction due to Hiatus Hernia in a 68-Year-Old Male

Dr. Rahul Pavanan et al. Large Gastric Obstruction due to Hiatus Hernia in a 68-Year-Old Male. Int. J Med. Pharm. Res., 6 (5): 1696‐1698, 2025 1696 International Journal of Medical and Pharmaceutical Research Online ISSN-2958-3683 | Print ISSN-2958-3675 Frequency: Bi-Monthly Available online on: https://ijmpr.in/ Case Report Large Gastric Obstruction due to Hiatus Hernia in a 68-Year-Old Male Dr. Rahul Pavanan1, Dr. Athulya Raj1 1 Department of Emergency Medicine A B S T R A C T Corresponding Author: Dr. Rahul Pavanan Department of Emergency Medicine Received: 02-08-2025 Accepted: 07-10-2025 Available online: 20-10-2025 A 68-year-old male presented with acute abdominal pain, coffee-brown vomitus, hypotension, and elevated lactate levels on arterial blood gas analysis. Past medical history included hypertension (HTN), obesity, severe gastritis, and obstructive sleep apnoea (OSA). A computed tomography (CT) scan revealed an anterior diaphragmatic hernia with significant gastric dilatation. This report discusses the presentation, diagnosis, and management of this life-threatening condition. Copyright © International Journal of Medical and Pharmaceutical Research Keywords: Acute abdominal pain; Diaphragmatic hernia; Gastric dilatation; Coffee-brown vomitus Case Presentation Clinical History and Examination: The patient presented to the emergency department with a 12-hour history of: - Severe epigastric and abdominal pain. - Persistent vomiting with coffee-brown contents. - Lightheadedness and fatigue. Upon examination: - Looks unwell, on oxygen for respiratory distress. Vital signs: - Blood pressure: 85/60 mmHg (hypotensive). - Heart rate: 110 beats/min (tachycardic). - Respiratory rate: 24 breaths/min (tachypnoeic). - Oxygen saturation: 90% on room air. Maintaining 94% on 2 litres oxygen General physical examination: - Obese male with pallor. - No cyanosis or peripheral oedema. Abdominal examination: - Distended abdomen with tenderness in the epigastric region. - Hypoactive bowel sounds. Investigations:1. Arterial blood gas (ABG): - PH 7.32 Pco25, P029, K3.2. Na -140 hco323 Elevated lactate: 4.8 mmol/L (suggestive of tissue hypoperfusion). - Mild metabolic acidosis, dehydration 2. Blood tests: - Haemoglobin: 10.5 g/dL (mild anaemia). - White blood cell count: 14,000/mm³ (leucocytosis). - Electrolytes: Mild hypokalaemia. - Creatinine: Elevated, suggestive of acute kidney injury. 3. imaging: - Computed tomography (CT) scan of the abdomen and pelvis: - Large anterior diaphragmatic hernia. - Significant gastric dilatation with part of the stomach herniated into the thoracic cavity. - Possible gastric volvulus. Past Medical HistoryHypertension (HTN): On amlodipine 10 mg daily. - Obesity: Body Mass Index (BMI): 33 kg/m². - Severe gastritis: Previously treated with proton pump inhibitors. - Obstructive Sleep Apnoea (OSA): On continuous positive airway pressure (CPAP) therapy. Diagnosis: Acute gastric obstruction secondary to a large anterior diaphragmatic (hiatal) hernia with probable gastric volvulus, complicated by hypovolemia and ischemia (as evidenced by elevated lactates and coffee-brown vomitus suggestive of upper gastrointestinal bleeding). Dr. Rahul Pavanan et al. Large Gastric Obstruction due to Hiatus Hernia in a 68-Year-Old Male. Int. J Med. Pharm. Res., 6 (5): 1696‐1698, 2025 1697 Management: Initial Stabilization 1. Resuscitation: - Intravenous fluids: Ringer’s lactate and normal saline boluses to address hypovolemia and hypotension. - Oxygen therapy: Administered via nasal cannula to maintain SpO₂ > 94%. - Nasogastric tube insertion: To decompress the dilated stomach. 2. Medications: - Empiric antibiotics: Broad-spectrum coverage (e.g., piperacillintazobactam) due to the risk of perforation and infection. - Proton pump inhibitors: High-dose IV pantoprazole to manage gastritis and prevent further bleeding. - Analgesics: IV paracetamol for pain management. Definitive Management 3. Surgical Intervention: - Emergency laparotomy was performed by the surgeons, due to the risk of gastric ischemia and perforation. - Findings during surgery: - Herniated, dilated stomach with evidence of partial volvulus. - No evidence of gastric necrosis. - Procedure: Reduction of the herniated stomach, repair of the diaphragmatic defect (hiatal hernia repair), and gastric decompression. 4. Postoperative Care: - Continued nasogastric decompression. - Gradual reintroduction of oral feeding. - Close monitoring of blood gases, lactate levels, and hemodynamic status. Outcome and Follow-Up: The patient recovered well postoperatively. He was discharged after 7 days with the following advice: - Weight loss and lifestyle modifications to address obesity. - Long-term use of proton pump inhibitors. - Followup with gastroenterology and surgery. - Assessment for CPAP therapy adherence for OSA. Figure 1: Diaphragmatic hernia Figure 2: looping of part of stomach in to the diaphragmatic defect causing pressure on the gastric out let. Dr. Rahul Pavanan et al. Large Gastric Obstruction due to Hiatus Hernia in a 68-Year-Old Male. Int. J Med. Pharm. Res., 6 (5): 1696‐1698, 2025 1698 Figure 3Gastric distension due to the the gastric outlet obstruction. DISCUSSION Hiatal hernias, particularly large or paraesophageal types, can lead to life-threatening complications, including gastric obstruction, volvulus, and ischemia. This case highlights the importance of prompt diagnosis and management of acute abdominal presentations in patients with known hernia history and risk factors such as obesity and gastritis. CONCLUSION Large hiatal hernias with gastric dilatation and volvulus pose significant risks, including perforation and ischemia. Early diagnosis with imaging and immediate surgical intervention are critical for a favourable outcome. REFERENCES 1. Kohn, G. P., Price, R. R., DeMeester, S. R., et al. (2013). Guidelines for the management of hiatal hernia. *Surgical Endoscopy*, 27(12), 4409–4428. 2. Spyropoulos, N., & Rattner, D. W. (2005). The history of hiatal hernia surgery: From Bowditch to laparoscopy. *Annals of Surgery*, 241(1), 185–193. 3. Eckhauser, F. E., & Zuckerman, G. R. (1992). Acute gastric volvulus: A case study and review of the literature. *American Journal of Gastroenterology*, 87(7), 848–854. 4. Mazurek, A., DE Goffin, R., & Cheynet, N. (2018). Acute gastric volvulus: An unusual complication of a hiatal hernia. *Journal of Gastrointestinal Surgery*, 22(5), 923–927. 5. Gastroenterological Society of Australia. (2017). 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