A Man With Two Gastric Bulbs

Question: An 82-year-old man presented to the emergency department with a 3-day history of dull epigastralgia. The physical examination was notable for distended abdomen and epigastric tenderness. Laboratory examination revealed elevated white blood cell count (14,200/μL), elevated serum lactate (3.1 mmol/L). A chest radiograph (Figure A) showed 1 sac with an air–fluid level around the right diaphragm symmetry to the gastric bulb below the left diaphragm. What is the diagnosis and how should it be managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. A computed tomography scan of the chest (Figure B, C) showed hiatal herniation with involvement of gastric antrum and transverse colon. Epigastralgia may be related to transverse colon and gastric antrum trapped in the hernia sac. We inserted a nasogastric tube for gastric decompression. After esophagogastroduodenoscopy ruled out gastric malignancy, a laparoscopic hiatal hernia repair was performed. During the surgery, the space of hiatal hernia in the thoracic cavity was checked, and the hernia sac was separated from pleura. The hernia sac was removed. Abdominal pain was relieved after surgery.